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THE FAIROHILD PREPARATIONS 



!BE PDRE DIGESTIVE FERIEITS, 

Active, Permanent and Reliable. 



TRYPSIN 

(fairchild) 

Especially Prepared as a Solvent for 
Diphtheritic Membrane, 



PEPTONISING TUBES. 

(fairchild). 

For the preparation of PEPTO- 
NIZED MILK and other 
predigested food for 
the sick. 



PEPSINE IN SCALES. 

(fairchild). 

The most active^ permanent and re^ 
liable pepsine made in the World, 



ESSENCE OF PEPSINE 

(fairchild). 

For administration where a fluid 
and agreeable form of pepsine is 
desired^ and for the prepara- 
tion of Junket and 
Whey, 



EXTRACTUM PANCREATIS. 

(fairchild). 

Containing all the digestive ferments 
of the Pancreas, 



PEPTOGENIC MILK POWDER 

(fairchild). 

For the modification of cows* milk 

to the standard of Normal 

Mother's Milk, 



PEPSINE IN POWDER. 

(fairchild). 

Prepared from the scales without the 
admixture of any other stib- 
stances f to facilitate dis- 
pensing and the pre- 
paration of saccharated pepsine. 



DIASTASIC ESSENCE OF 
PANCREAS. 

(fairchild). 
For the digestion of starchy foods. 



Fairchild Bros. & Foster, 

82 AND 84 FULTON ST.. NEW YORK. 



RHEUMATISM 



AND 



GOUT 



J » U J 

-> ■» » 



*•* 



J 
J 



^ w •# 



— BY — 

F. LE EOY SATTEBLEE, M.D., Ph.D., 

Prcf^ior of Chemistry^ Materia Medica and Therapeutics in tJie New 
York CoUege of Dentistry; late Professor of Chemistry and Hygiene 
American Veterinary CoUege: Hon. Member Society of Arts^ luofn- 
don. Eng.j Attending Physician 8t Elizabeth Hospital^ New 
York; Consulting Physician Midnight Mission; late At- 
tending Physician Northeastem Diimensary^ Depart- 
ment of Skin and Sheum^itism; F'ellow ofNTT. 
Academy of Medicine; Fellow of Academy of 
Sciences; Fellow of Oeographtcal Society; 
Member of County Medical Society^ 
N. T.; Member of Medico-Legal 
Society, and Member of Path- 
ological Society^ N. T. ; etc. 





1890. 
GBORGB S. DAVIS, 

DBTROIT, MICH. 






Iom0 



3 






• • • 

• • • • 

• • • 



• • •• • 

• • • 

• • ••• 



• • 



• • 



• • 



Copyrighted by 
GEORGE 6. DAVIS. 

1800. 



• • • 

• • • • 




L1S8 

ist>o 



DEDICATION. 



Affectionately dedicated to my wife, who by her eare, 
sympathy, and encouragement, did so much to enable the 
author to overcome in himself the ailments treated of in 
this book. 



TABLE OF CONTENTS. 



Paos. 

Argument > . . . . i 

Acute Articular Rheumatism 7 

Chronic Articular Rheumatism 35 

Rheumatoid Arthritis 50 

Gout 60 

Analyses of Mineral Waters 74 

Index 79 



PREFACE. 



It was not to allay the irritation of an attack of cacoetkes 
scribendi that this brochure was attempted, neither was it the 
unwarrantable assumption that upon the subject matter there 
was anything new to offer, but rather the yielding to the 
wishes of medical friends and the conviction that in the 
labyrinth of newer theories it was possible to lose tenable 
hypotheses and neglect valuable therapeutic resources. Driven 
by the stem necessities of an obstinately developed inherited 
rheumatic and gouty dyscrasia, which threatened the early 
abandonment of his professional career, the author was com- 
pelled to carefully study these diseases. The uric-acid theory 
of causation and whatever may be physiologic^ Uy and path- 
ologically connected therewith, seeming feasible and sound, 
he was able by the persistent adoption of the therapeutic and 
dietetic measures indicated to completely eradicate every 
symptom of the trouble in himself. Conscious, however, thai 
the too implicit acceptance of theories, whether self-evolved or 
based upon deductions of others, is to close the mind to the 
appreciation of progress, what has been written is intended 
only to convey, without dogmatism, the formulated opinions 
which have gained force after twenty- five years' experience, 
with a natural predilection for the treatment of rheumatism 
and gout. 

F. Le Roy Satterles. 
8 West xlth Street. 



ARGUMENT. 

Since medicine has possessed a literature, the 
clinical history of rheumatism and gout has been 
made the subject-matter of text-book and special 
treatises ad nauseam. The brief consideration of 
causation, symptomatology, and so forth, is intro- 
troduced into this brochure for the sake of continuity 
and compactness, the author waiving all claim to 
originality in description or research. The pheno- 
mena, which in the main characterize these diseases, 
are the same yesterday, to-day and forever. 

In the matter of treatment, however, he feels 
that he may, out of a ripe experience, with justice to 
himself, and in the hope of possible benefit to others, 
state the satisfactory results which appear to have 
accrued by following the lines to be hereinafter de- 
tailed. 

As to the possible relation which the presence of 
an abnormal quantity of uric acid in the system, re- 
sulting from a failure in the process of oxidation to 
the point of urea, bears to the theoretical bases of 
identity for cause and treatment in rheumatic affec- 
tions, an epitome of several views may be permitted 
without venturing too far upon debatable ground. 

It has been urged that there exists a large class 
of diseases which can be proved to result from errors 
of chemical action, caused by the introduction from 
without, or by the generation within the body, of sub- 

I NN 



2 — 



Stances that increase or .diminish, or change the 
oxidation which is necessary to its special working. 

It is essential to the precise constitution of 
healthy blood, that there shall exist an accurate 
balance in the nutritive processes maintaining the 
several tissues, so that none of the materials appro- 
priated to any part may remain in excess in the 
blood. Thus each part is in the relation of an ex- 
ecretory organ to all the rest. For example, if the 
muscles do not take material for their nutrition, there 
may be an excess of fibrin and their other constitu- 
ents in the blood; if the bones do not do so, the salts 
of lime may be in excess, and so on. 

Among the causes likely to disturb this theo- 
retical chemical equilibrium, are the presence in ex- 
cess, of some given constituent of the food, and the 
existence of any condition calculated to effect re- 
tardation in the normal change of tissue, preventing 
the appropriation of new material for the construction 
of healthy blood. Experience unquestionably shows 
that gout, and allied affections, are met with in in- 
dividuals addicted to an over-indulgence in nitrogen- 
ous diet and generous wines, and who are given to 
sedentary habits. These conditions are intimately 
associated with the presence of uric and oxalic acids 
in the blood, and their manifestations. The amount 
of fibrin in healthy blood is less than three per cent. 
In rheumatism this constituent may be abnormally in- 
creased to ten per cent. Excessive indulgence in 




— 3 — 

nitrogenous diet, causing excess of fibrin in the blood, 
and conditions which retard the transformation of 
effete tissue, is likely, therefore, to render the normal 
supply of atmospheric air insufficient for its required 
purposes in the economy. A sedentary life, inde- 
pendent of the foregoing, also retards metamorphosis. 
Under these circumstances, it follows that if urea, 
carbonic acid, and ammonia, represent the full oxida- 
tion of the proteids in the body, anything short of 
this must result in the production of intermediate 
compounds. Uric acid, for example, which is formed 
in all warm-blooded animals, must be for the most 
part further oxidized or, owing to its insolubility, it 
will be deposited or combined with alkaline bases 
producing calculous diseases. 

It is stated that when uric acid is subjected to 
the action of oxygen, it is first resolved into alloxan 
and urea; a new supply of oxygen acting on the 
alloxan causes it to resolve itself into oxalic acid and 
urea. The various excretions, as we know, are simply 
removed by the emunctories; and these excretions, it 
seems, must be in some required chemical condition, 
or they are imperfectly removed and otherwise re- 
main as abnormal disturbants. The varied phases of 
interference in the vital economies produced by these 
abnormal conditions, we can only perceive by observa- 
tions of results and existing states; the molecular 
methods that determine the specific exhibitions of 
disease are as yet beyond our ken. What we do per- 



— 4 — 

ceive is, that a certain state of oxidation is a prime 
necessity for elimination. Urea represents the oxida- 
tion, more or less complete, of effete material, or of 
superfluous protein matter in the circulation. If this 
oxidation of the proteids is not sufficiently complete, 
intermediate compounds are formed, and these con- 
stitute the materies morbi of certain diseases, such as 
rheumatism, etc. While uric acid may be a normal 
constituent of the urine, it should exist in but small 
quantity; hence the greater part of it is, in the system 
raised, so to speak, by oxidation to urea. The kid- 
neys do not, then, form urea, but merely remove it 
fronl the blood where it has been created by chemical 
changes. 

Urea, carbonic acid, water, ammonia, etc., are 
the results of the ultimate oxidation of effete tissue, 
not by direct oxidation, but after a series of chemical 
evolutions. In gout and rhumatism, in which there 
is an excess of fibrin and uric acid in the blood, and 
excess of uric acid ip the urine, and on the part of 
the patient, sedentary and indulgent habits, we find 
affections of the white tissues, sheaths of muscles, 
aponeuroses, bursse, capsular ligaments, pericardium 
and endocardium, and deposition of urate of soda in 
the joints, and we look for a deficient oxidation of 
effete tissue as the immediate cause of these affections. 
This theory is well corroborated by the opposite con- 
ditions which occur in the pyrexiae, in which class of 
diseases there is super-oxidation of tissue, as repre- 




— 5 — 

seated in excessive execretion of nitrogenous com- 
pounds from the body, calling for such medicinal 
agents as counteract oxidation. 

In recapitulation, it may be assumed for the sake 
of argument that certain habits of body tend to the 
undue accumulation of proteids in the blood; that 
these are then absolutely in excess, relatively to the 
wants of the system, and to the amount of oxygen 
consumed; that urea, carbonic acid, and ammonia re- 
present the full oxidation of proteids, and when this 
process is imperfect, the formation of intermediate 
products must result. The primary morbific cause of 
gout, rheumatism, and allied affections, is the result 
of the imperfect oxidation of effete tissue. Treatment 
based upon this assumption is always the most suc- 
cessful. In gout and rheumatism, then, it is inferred 
theoretically, on the best possible grounds, and prac- 
tically on the evidences of our senses, that there is an 
excess of uric acid circulating in the blood. The ac- 
ceptance of this theory is quite compatible with the 
admission of the possible presence of any specific 
micro-organism developing in suitably vitiated tissues 
or blood, and conducing to, or inducing, certain of 
the pathological phenomena of acute rheumatism. 

Theoretically, then, the problem of treatment and 
allied affections is reduced to a simple equation. De- 
crease the amount of nitrogenous food taken into the 
body, by restricting the diet, and give such remedies as 
will promote oxidation, so that the excess of nitroge- 



nous material may be oxidized up to the point where 
it is easily eliminated from the body. 

From a chemical point of view, the alkaline salts 
constitute the most important principles promoting 
oxidation; even vegetable acids are converted in the 
system into carbonates for this purpose. The alkalies 
do not neutralize the uric acid, as was a^ one time 
supposed, but merely prevent its accumulation to the 
extent which constitutes a materies morbi^ by pron^pt- 
ing its oxidation to the point of urea formation. 



CHAPTER I. 

ACUTE ARTICULAR RHEUMATISM. 

DEFINITION. 

A constitutional febrile disease, the immediate 
local manifestations of which are painful inflamma- 
tory changes at the site of the articulations, several or 
many of which may be simultaneously involved. 

CAUSATION. 

Innumerable theories have been from time to 
time advanced, and one by one abandoned, as to the 
real causes active in producing an attack of acute 
articular rheumatism. The tendency of present med- 
ical thought is, to ascribe all pronounced morbid 
systemic disruptions to the presence of some specific 
organic pathogenetic poison, and acute rheumatism is 
receiving its quota of scientific investigation in this 
respect. 

Any physician, therefore, posing as abreast of 
current thought, must stand prepared to give credence 
to well authenticated proof that the germ of rheuma- 
tism has been isolated. 

Pending such demonstration, that which is 
known as the uric acid theory of causation is perhaps 
the most tenable and unassailable; at any rate, it is a 
fact that treatment, though based even vaguely upon 
this guasi'Scientific hypothesis, has proved so far the 



— 8 — 

most universally successful. It is probable, however, 
that many of the ingenious surmises hitherto assidu- 
ously promulgated, have contained elements of truth 
essential as factors to the perfect solution of the prob- 
lem as to the definite aetiology of this disease. 

Accepting, then, the remote causation of acute 
rheumatism as admitting of no present demonstration, 
we must fain be content with the consideration of the 
more immediate influences which appear to result in 
its exhibition. 

The attempt to locate the disease as especially 
prevalent in certain climates, or under certain atmos- 
pheric conditions, does not seem to have been any too 
successful, authors of note disagreeing upon main 
issues. Perhaps the fact as to this point is well cov- 
ered by the statement that it is prevalent throughout 
the temperate zones, less so in the tropics, while in 
the polar regions its occurrence is rare. 

Perhaps there is no malady in which individual 
predisposition, inherited or acquired, but especially 
the latter, plays such an important rdle as in acute 
rheumatism. Apart from the congenital dyscrasia, 
there are numberless influences to which people are 
exposed, tending to such vitiation of the physio- 
logical constituents of the body as renders immi- 
nent the liability to an acute manifestation of this 
disease. Formulae abound, all of which have in turn 
served to demonstrate, to the satisfaction at least 
of the medical mathematicians by whom they were 




— 9 — 

evolved, the precise molecular metabolism incident to 
acute articular rheumatism. These recondite propo- 
sitions are periodically set aside, often in favor of 
still more complex theories. 

It is, however, manifest that irregularities of liv- 
ing, errors of diet, and protracted exposure to impure 
atmospheric influences, especially when associated 
with humidity, seem to prepare in the system mor- 
bific combinations ready for explosion in the form of 
an inflammatory attack, upon the exhibition of an 
adequate exciting influence. 

This predisposition once established, the potent ex- 
citing cause which usually determines the first clinical 
phenomenon is cold. This influence may act directly 
or insidiously. Exposure to such sudden lowering of 
the temperature as produces a chilling of the super- 
ficies of the body, especially when perspiring, fatigue, 
wearing damp clothes, or during or after severe 
bodily exertion, is a direct cause, while draughts im- 
pinging upon any portion of the body, and steadily 
or rapidly lowering the temperature over an area of 
more or less of its surface, may act insidiously in pro- 
ducing the attack. While none of these factors may 
be grossly definable, there is little doubt that they, or 
some intangible modification of them, exist prior to 
an acute seizure. 

Whether the resultant phenomena called rheu- 
matism, could accrue from these exciting causes with- 
out due preparation of the system by the morbific 



lO 

processes already indicated, is a moot point. While 
admitting the potency of such exciting causes for the 
production of many other of the acute ailments, the 
author ventures to assume that only in the presence 
of certain properly arranged morbific elements, con- 
stituting the dyscrasia or predisposition, would the 
particular phenomena of acute articular rheumatism 
be determined. This position seems to leave ample 
margin for the acceptance of the theory of specific 
microbic investment, by the blood or tissues, preceding 
or co-incident with the exciting cause, should further 
investigation demonstrate the disease as partly or 
wholly of infectious origin. 

The writer, in a paper read before the New York 
Dermatological Society, some seventeen years ago, 
committed himself to the view that his observation 
had indicated the non-existence, in the same subject, 
of rheumatism and consumption. A contributor to 
current medical literature has recently definitely stated 
the belief that there is an antagonistic inherited 
cachexia precluding the simultaneous or consecutive 
existence in the same individual of phthisis and rheu- 
matism. 

While neither age nor sex can be said to enjoy ab- 
solute immunity from the malady, it appears to favor 
by selection the periods of juvenility, adolescence, and 
middle age. In very young children it is infrequent, 
and an initial acute attack is rare after forty-five, or 
fifty. 



II 



To sum up: Heredity, imperfect hygienic influ- 
ences, especially if associated with humidity, imp;^^p«r 
alimentation, faulty assimilation, sub-oxidatij(|g^ the 
nitrogenous constituents of the body .^wircharging 
the economy with resultant uric aqi^ ^^md other pro- 
ducts of the arrested oxidation^jd^s the development 
of some specific germ yet H^ t)e demonstrated, may, 
with exposure to coWjk an accentuated or perhaps 
an intangible ea^ctting cause, produce the inflamma- 
tory CQiuHltkm which we know as acute articular rheu- 

SYMPTOMATOLOGY. 

Until the sensations of the patient are sufficiently 
defined to refer to pain as localized in the joints, the 
symptoms of an impending attack of acute rheuma- 
tism could only be covered by a list of possibilities, 
the systemic disturbances, constituting predisposition, 
which render the attack imminent, may ivell account 
for any pre-existing malaise. As this disturbance 
varies in degree, so may the indications be pronounced 
or almost absent. Assuming the case to be a first at- 
tack, uncomplicated, yet typical in point of rheumatic 
indication, there may exist on the part of the patient a 
premonition that something is wrong. Some muscular 
soreness, weariness in the limbs, neuralgic pains, stiff- 
ness about one or more of the joints, associated with 
impairment of the appetite and constipation, may each 
and all be experienced. Laryngitis and amygdalitis 
are not infrequently present, and many laryngologists 



12 



to-day recognize the possibility of these affections 
being sometimes of rheumatic origin, and assert 
that the symptoms may then be rapidly and effect- 
ively controlled by anti-rheumatic treatment. Dis- 
tinct rigor is probably rare, but chilly sensations 
may be present, and the temperature if taken at 
this time, may be found at ioi° F. Pain, of charac- 
teristic and ever increasing severity, is gradually con- 
centrated about certain of the articulations. The 
slightest movement of the body, contact of the bed- 
clothing, the motion imparted to the bed by attend- 
ants walking in the room, and the performances of 
the necessary nursing offices, are sources of exquisite 
suffering. Nothing short of absolute immobility 
gives any approach to relief. The temperature will 
now be found to have risen to 103° or 104° F. Ex- 
amination of the affected areas may reveal nothing, 
and it is a point of clinical interest that the intensity 
of the suffering can be so disproportionate to the 
external evidences of the inflammatory processes. 

Again, examination of the affected joints may re- 
veal all the appearances of acute synovitis, tender- 
ness, swelling, fluctuation from effusion, and oedema, 
a circumscribed or diffused inflammatory blush being 
well defined. 

The larger articulations are more generally at- 
tacked, notably those of the lower extremities, but 
the fingers are often implicated, and there is no 
exemption in favor of any articular site. 




— 13 — 

It is characteristic of the malady, that after in- 
vading a series of joints, the inflammatory processes 
may cease in them somewhat suddenly, migrating to 
other articulations, and leaving those originally affected 
comparatively comfortable. When this amelioration 
does not obtain, the condition of the patient becomes, 
of course, correspondingly pitiable. Such metastatic 
excursions may be repeated de novo, 

Hyperidrosis is constant to acute rheumatism, 
and the intense acidity of the sweat secreted probably 
induces those skin affections which are. by no means 
uncommon during the attack. There may occur 
eczemas, urticaria, erythema nodosum, papular efflor- 
escences, sudamina, and herpetic eruptions. 

The departure from the normal standard in the 
character and quality of the urine secreted and ex- 
creted during this disease is quite marked. The 
quantity voided in twenty- four hours is far below that 
of health. The color is deep red, the reaction is in- 
tensely acid, the specific gravity high, and on cooling 
there is subsidence in excess of such solid constituents 
as free uric acid and the urate of soda. 

The diminution in the quantity of the urine 
voided may be fairly credited to the drain upon the 
watery constituents of the tissues by the profuse per- 
spiration, and the evaporation under high temperature. 

The febrile phenomena vary greatly in this dis- 
ease. The thermometric curve may be tersely ex- 
pressed as proportionate to the area of the articular 



— 14 — 

sites involved. Remissions, or even intermissions, of 
temperature are common enough, and evening ex- 
acerbations are the rule. The pulse corresponds in 
frequency and character to the temperature, and to the 
extent with which complications arise involving the 
heart and great vessels, and the nervous centres. 

DIAGNOSIS. 

A disease presenting such clinical manifestations 
hardly admits of much argument on points of refine- 
ment in differential diagnosis. Still there are diseases 
with which are associated pain and swelling of the 
joints, with or without febrile disturbances, which, 
it is well to bear in mind, and to satisfactorily ex- 
clude. Among these are traumatic arthritis, osteo- 
myelitis, acute gout, acute rheumatoid arthritis, 
pyaemia, gonorrhoeal rheumatism, and hysterical 
joint. Traumatic arthritis is usually determined by 
a history or evidence of injury, and is confined to one 
articulation. Gonorrhoeal or urethral rheumatism 
generally attacks one joint only, and that in the lower 
extremities. Acute gout manifests itself in the ball of 
the great toe, or, if disseminated, is not associated with 
such marked constitutional disturbances. Rheumatoid 
arthritis is not migratory, and is unattended by gen- 
eral symptoms. Hysterical joint is said to depend for 
its clinical features upon mental concentration on the 
part of the patient, for when the attention is di- 



— 15 — 

verted the site of the alleged lesion can be roughly 
handled with impunity. 

With due regard to the history of any given case 
and careful observation of its clinical aspects, there 
should be found no difficulty in arriving at a correct 
diagnosis in a case of acute rheumatism. Bearing in 
mind, however, the grave cardiac complications which 
may accompany or even antedate the condition of 
maximum severity, it is important, when the diagnosis 
is once made, that special regard should be paid to 
their existence or possible appearance. 

PATHOLOGY. 

Though acute rheumatism is one of the most 
common diseases, it is so seldom fatal that oppor- 
tunities for extended post-mortem investigation 
do not occur; hence the very meagre information 
available on this point in pathological literature. It 
is, however, admitted that the changes within the 
joints are usually slight, and bear little relation to the 
clinical symptoms. The diffused or circumscribed 
blush which might have been present at the time of 
death, disappears post-mortem. If the examination 
be made soon enough there will be found a more or 
less vivid hyperaemic condition of the synovial mem- 
branes of the affected joints, the membranes being 
lustreless and granular — and this may be all. In 
special cases the joint may be distended with fluid, 
while all the existing exudations will be turbid from 



— i6 — 

the presence of fibrin, and of a pinkish hue from 
slight extravasation of blood. The joint surfaces are 
sometimes pink from congestion of the vessels; flakes 
of lymph float free or coat the synovial surfaces of 
the joints. The inflammatory processes are at times 
seen to extend to the sheaths of the tendons, fascia, 
and muscular structures; there is marked abnormal 
proliferation of cell elements, and some indications of 
fatty degeneration; the ends of the bones are more 
than usually vascular. 

Such a list of possibilities hardly bears out the 
statement of meagreness in pathology, but in fact the 
appearances are but rarely so defined. 

COURSE AND TERMINATION. 

A typically severe case of uncomplicated acute 
rheumatism tends, if it is the first attack, to subsid- 
ence of all the painful symptoms about the middle or 
end of the third week. When recovery is retarded it 
is generally so protracted by co-existing complica- 
tions. 

Cases which run a sub-febrile course are gener- 
ally of mild character and of short duration. The 
disease may terminate in perfect recovery; recovery 
with more or less impairment of function, at the site 
of the affected joints; recovery with a permanent 
cardiac lesion; or in the event of the possible, though 
rare supervention of cerebral symptoms, with pro- 
nounced and sudden exacerbation of temperature, 
death may ensue. 




— . 17 — 

Perhaps the sharper and more well defined the 
attack, if uncomplicated and fairly treated, the less 
the liability to protracted sequelee referred to the 
joints; the milder sub-acute and often less cared for 
cases appearing more frequently to drift into a state 
of chronicity. 

Undoubtedly, the severity of the course, and the 
duration of the attack, can be influenced and miti- 
gated by scientifically directed treatment, which tends 
also to minimize the probability of chronic functional 
impairment of the joints, and to ward off the more 
grave cardiac complications. 

COMPLICATIONS. 

For the purpose of concise description, a case of 
uncomplicated rheumatism has been assumed. The 
fact must not been ignored, however, that the proba- 
ble, too often unavoidable, and always irremediable, 
cardiac lesions, which may antedate or coexist with 
the acute symptoms, are to be regarded as possible 
components of the general rheumatic condition. 
These lesions are of so serious a character as to far 
exceed in significance all the other manifestations of 
the disease. Pericarditis and endocarditis, with which 
more or less myocarditis is associated by contiguity, 
can and often do arise. Opinions are so at variance 
as to the condition and circumstances in which these 
heart complications are most prone to occur, that 
individual statement has little weight. 

3 NN 



— i8 — 

It is, however, received as an axiom, that they 
are the more likely to arise, the younger the subject. 
It is also stated that the danger of involvement of the 
endocardium bears direct proportion to the severity 
of the seizure, and to the size, number, and position of 
the joints attacked. It has been lately urged, and with 
much reason in the argument, that many cases of de- 
veloped heart disease in the adult might be traced for 
their origin to an unappreciated rheumatic condition in 
early life. The point is well made, that the nature of 
the rheumatism which attacks children is often ob- 
scure, and that in view of the well known difference in 
the degree of severity in this disease, many children 
experiencing the so-called " growing pains " are suffer- 
ing from rheumatism with possible associated endocar- 
ditis. The delicate softened heart-muscles, it is 
claimed, might readily at such a time undergo dilata- 
tion, with permanent damage to the valves. In the 
event of the child's surroundings being of such a char- 
acter that nutrition remained adequate, the necessary 
compensatory hypertrophy would ensue, enabling the 
heart to do its work, but that when waning vitality 

■ 

supervened, the existence of valvular lesions would 
become evident. 

It is not within the scope of this writing to dis- 
cuss the clinical and physical aspects of the heart 
lesions. It should, however, be borne in mind, that 
a variety of murmurs may be definable over the prae- 
cordial area, many of which may be the result of tem- 



— 19 — 

porary functional disturbances. In pericarditis, the 
opposed inflammatory products upon the interior of 
the sac will give rise, during the movements of the 
heart, to a characteristic friction murmur, prior to the 
«tage of effusion. If the patient is thin, palpation 
of the region may elicit a friction fremitus. The ex- 
istence of any considerable effusion in the sac will of 
■course give rise to proportionate displacement of the 
heart and lungs, with corresponding dyspnoea and 
circulatory disturbances, and increased area of cardiac 
-dullness. 

The clinical points in endocarditis are not well 
•defined, but too much significance cannot be placed 
upon the presence of a systolic mitral murmur during 
a first attack of acute rheumatism in a person known 
to have been previously free from any heart trouble. 

Among the rarer complications of the acute 
•stage, may be cerebral or hyperpyretic rheumatism, 
meningitis, pyaemia, pleurisy, pneumonia, and bronchi- 
tis. Chorea, and follicular tonsilitis, are said to have 
acute rheumatism as a most potent factor in their 
causation. 



CHAPTER II. 

TREATMENT OF ACUTE RHEUMATISM. 

The subject of treatment in this disease has been, 
and still remains vexata quastio. The theories from, 
time to time coming to the fore as to the morbific 
processes constituting its pathology, have each had 
thereto appended suggestions for a course of treat- 
ment to be specific, or of more or less pronounced in- 
fallibility in mitigation or cure. Treatment by 
placeboy such as colored water, mint water, etc., during^ 
an acute attack, has demonstrated the expectant 
method as deleterious, the systemic disturbances and 
dangerous complications demanding medical inter- 
ference. Many hitherto vaunted specific remedies, 
no matter how well chosen or assiduously adminis- 
tered, are powerless to do more than temporarily al 
leviate aggravated symptoms; they do not shorten the 
disease and their use is frequently pernicious, and too 
often fraught with grave dangers. In this class of 
remedial measures and agents are phlebotomy, once 
practiced heroically in rheumatism, and the use of the 
antimonial and mercurial preparations. Then follow 
a long list of therapeutic agents, among the most 
popular of which have been the nitrates and bicarbon- 
ates of soda or potassium, quinine, colchicum, iron, 
iodide of potassium, opium, aconite, veratrum, lemon 
juice, oil of wintergreen, digitalis, the mineral acids. 



21 



trimethylamine or its hydrochlorate, salol, salicylic 
acid, the salicylates and benzoates. 

The topical remedies have included every con- 
ceivable device from a cabbage leaf to blisters and 
the subcutaneous injection of thirteen drops of a one 
per cent, solution of carbolic acid at the site of the 
affected joints. 

As in the consideration of the symptomatology 
of this disease the occurrence of a typical uncom- 
plicated case, coming under the physician's notice 
in its initial stage, was assumed as a basis for general 
description, so*in dealing with the question of treat- 
ment it is convenient to continue upon a similar basis. 
It must be borne in mind, however, that the phases 
of the disease in degrees of severity, and the social 
and hygenic entourage of the patient, are factors 
powerful for'good or evil under precisely similar lines 
of treatment. 

The writer is in the habit of dividing and sub- 
dividing the heads of a routine treatment, subject to 
modificationsTwhich may be indicated during the 
progress of the case, pretty much as follows: 

rCholagogues. 

Alkalies. 
J Antipyretics. 
j Analgesics. 

Mineral waters. 
y Tonics. 

( Topical applications, 
•j Batbs. 
( Massage. 



Constitutional. 



I. Medicinal. 



Local. 



— 22 



^. . , i Liquids. 

2. Dietetic. ^ Solids. 

3 The treatment of special symptoms and complica- 
tions. 

The dosage to be suggested is for adult patients^ 
and must be graded for youth according to the ac- 
cepted methods. 

CHOLAGOGUES. 

It is believed by many authorities, and is an 
opinion in which the writer concurs, that the pres- 
ence during an acute rheumatic seizure, of uric acid 
in excess, is due in a measure to the failure on the 
part of the liver to supply bile in sufficient quantity 
to complete, with the pancreatic fluid, the process of 
saponification of the various food elements, leaving- 
them merely emulsified. The absorption of the 
chemical products of such emulsification through the 
portal system, deranges the glycogenic and cognate 
functions of the liver, leading to the formation in 
excess of uric acid, and to the arrest of subsequent 
processes by which it should be converted or elim- 
inated. Physiologically, bile should be of alkaline 
reaction; but, in rheumatism, or under the influence 
of an excessive animal diet, it is in a state of more or 
less intense acidity, which tends to the precipitation 
of cholesterine and the production of calculi so often 
associated with the rheumatic condition. As chola- 
gogues are decidedly indicated in the treatment of 
biliary lithiasis, so we must include them in the treat- 




— 23 — 

ment of all forms of rheumatism, exhibiting such 
drugs as by their known or assumed selective action 
in stimulating the functions of the liver, are the most 
likely to relieve the biliary stasis referred to. For 
this purpose, podophyllin will be found of undoubted 
utility. It may be given in doses of a quarter of a 
grain, once, twice or thrice in the twenty-four hours, 
as may be desirable. Euonymin is also a valuable 
cholagogue, and may be administered in doses of two 
or three grains at night, with three grains of Castile 
soap. Perhaps the more elegant and useful combina- 
tion would be in tablets, each to contain: 

Q -Euonymin. X g^^^^ 
' Podophyllin, yi grain. 
Aloin, % grain. 
Sig. — One tablet morning and night as required. 

ALKALIES. 

Having arranged for the foregoing part of the 
treatment, as of preliminary importance, attention 
must be given at once to the question of the essential 
means by which it is hoped the course of the disease 
may be mitigated and curtailed, and the chances of 
cardiac involvement minimized. If such a desirable 
result is to be effected by medicinal methods, it will be 
done by the prompt and judicious, but complete and 
persistent, saturation of the system by some simple 
and bland alkali, the continued presence of which will 
so nullify the pernicious effects of the abnormally 
secreted uric acid, as to render it nugatory until the 



— 24 — 

complete explosion of the forces which determine its 
excess, shall have taken place. The sodium alkalies 
are the best, and of these sodium bi- carbonate is to 
be preferred. It should be given in one-drachm 
doses every two hours, and its use persisted in until 
the saliva, which is acid in acute rheumatism, and 
the sweat and urine are found to give no acid reaction 
to blue litnius paper, with which, by the way, every 
physician should be provided when attending a case 
of this kind. 

Sodium phosphate may also be given if preferred, 
in one drachm doses, dissolved in about two ounces 
of water. These sodium and potassium salts may be 
administered conveniently in Vichy water, or in an 
effervescing drink with a vegetable acid. 

Q Potassii bicarbonatis. 3ii, Bii. 
Aquae distillata, § viii. 
M. Sig. Oae fluidounce of this solution to half an ounce 
of fresh lemon juice. To be taken while effervescing. 

The writer has found the following combination 

of alkalies effective, and to be well borne by the 

stomach: 

Q Lithii benzoatis, 3 ss. 

Sodii bromidi, 

Potassii carbonatis (pura), aa 3 ij. 
Potassii acetatis, § iss. 
Sodii phosphatis, § ss. 
Syr. zingiberis, 
Aq. menth. pip., ^ ad | vj. 
M. et slg. 
Two teaspoonfuls to a tablespoon ful, in a half a glass of 
water, every four or six hours, after food. 



I 



-- 25 — 

The thorough alkalinization of the system being 
demonstrated to the satisfaction of the physician, the 
dosage must be so graded, in respect to time and 
quantity, as to secure the permanence of the condition 
without uncalled-for crowding of the remedies, a re- 
turn being promptly made to such quantities as will 
maintain saturation, in the event of the litmus reaction 
test denoting that the acidity is regaining ground. 
This should be done for a week or ten days in a 
typically severe case, without waiting for painful ex- 
acerbations on the part of the patient as an indication 
for resumption of the alkaline remedies. 

The writer does not approve of, or recommend 
the employment of salicylic acid, or the salicylates, in 
the treatment of cases of acute rheumatism. The 
effect of these drugs, though at times brilliant in pro- 
ducing subsidence of pain, is very uncertain and 
always transient, relapses being the rule; and the con- 
tinued administration of these remedies is, moreover, 
productive of a series of deleterious symptoms, such 
as gastric and cerebral disturbances, cardiac depres- 
sion, obliteration of the first sound of the heart, 
anaemia, and other toxic phenomena. 

In the most recently published views upon the 
subject of the salicylic compounds as applicable to 
acute rheumatism it is urged that while they are of 
special utility in relieving pain, their use does not 
lessen the tendency to cardiac complications or hyper- 
pyrexia, and that they are powerless to cure these 



— 26 — 

when they do arise. In addition to such negative 
properties it has been observed that salicylism may 
induce certain hsemorrhagic conditions, such as epi- 
staxis, bleeding from the gums, hsematuria, and reti- 
nal haeorrhage. 

This is rather a bad record for so vaunted a 
specific. 

ANTIPYRETICS. 

Exacerbations of temperature must be met as, in 
the opinion of the physician, the necessity for inter- 
ference may arise, and in this particular it is well to 
exercise judgment and to carefully watch the pa- 
tient. It is not possible to define dogmatically the 
safety limit in the matter of the pyrexia, but it is 
necessary to urge caution in the administration of the 
several potent modern remedies which seem under 
certain conditions to control thermogenesis. Judici- 
ous use of these antipyretics in a case of acute rheu- 
matism, where the temperature shows persistent tend- 
ency to run up to 103° or 104° F., would probably 
consist in the administration of antipyrin, antifebrin, 
or phenacetin in such doses, and at such intervals, as 
to maintain an equable temperature of 101° F. By 
such careful grading a bearable condition is secured 
to the patient, while general depression is avoided, and 
the heart loses none of its essentially demanded power 
to keep up the active circulation necessary to the re- 
storation of a physiological equilibrium. Antipyrin 
may be given with safety in ten grain doses every 



— 27 — 

three or six hours, antifebrin in five grain doses every 
five or six hours, and phenacetin in ten grain doses 
every six hours. To further guard against the a^ion 
of these drugs as depressants, it is an excellent rule 
to combine with each dose half a grain of powdered 
digitalis. 

Quinine, which has been so indefatigably given 
in acute rheumatifiiiv as well as in almost every other 
ailment jiatSesh is heir to, while it has its place, is 
than useless in the acute stage of this disease. 



ANALGESICS. 

Antipyrin, antifebrin, and phenacetin, possess 
marked analgesic properties, and in the majority of 
cases will, with the alkalinity of the system, be all that 
is required to make the condition bearable. When 
the pain is very intense, especially at the period of 
maximum severity in the disease, a hypodermic injec- 
jection of morphia may be given, but it must be put 
off as long as possible, and the frequent repetition of 
this useful but insidious drug should be avoided for 
obvious reasons. If an interval of natural and pain- 
less sleep is urgently indicated, the following will be 
found effective: 

Q Morphias sulphatis gr. jl^. 

Potassii bromidii gr. xxx 

Chloral hydratis gr. xx. 

Syrupi aurantii cort 3 ii. 

Aquae pura q. s. ad. § i. 

M. et sig. Take at one dose, say at ten o'clock at night. 



— 28 — 
MINERAL WATERS. 

The mineral waters which may be esteemed as of 
possible medicinal benefit in acute rheumatism are, 
chiefly, Vichy and Rubinat Llarach. The former may 
be used freely throughout the entire treatment, and is 
a serviceable vehicle for the administration of the 
alkaline remedies. The Rubinat Llarach is richer in 
sodium sulphate than other waters of this type, and is 
valuable for its action on the liver, and may be pre- 
scribed with advantage in any form of rheumatism. 
A wineglassf ul is about the dose, to be given early 
each morning, followed shortly afterward by a cup of 
hot coffee or tea. 

TONICS. 

When the inflammatory symptoms have well sub- 
sided, and the emunctories are apparently acting 
normally, it will be well to administer a course of 
routine treatment, the details of which hardly demand 
notice here. Attention should, however, be directed 
to the heart, with a view to the restoration of its 
tonicity. Whether this organ has escaped permanent 
damage or not, it will be well to assume its need of 
special medication. Digitalis, strychnine, arsenic, iron, 
quinine, in any of their innumerable combinations, 
may be utilized now. Probably the freshly prepared 
infusions or decoctions of cinchona bark, combined 
with a mineral acid, will be found really more effectual 
than quinine in restoring appetite during convales- 




— 29 — 

cence. Lactopeptine may be given if there remains 
any gastric irritability. The following mixtures are 
suggested as reliable tonics: 

9 Tinctura ferri chloridi 3 iv. 

Tinctura nucis vomicae, [ hh rr 

Acidi phosphorici dil. J ^ ^ *J- 

Syrupi aurantii cort § j. 

Elix. Calisayae q. s. ad J tj. 

M., et sig.: A teaspoonful in wineglass of water three 
times a day, half an hour before meals. 

Or, 

3 Cinchona flav. cort 3 iij. 

Aquae bulliens § v. 

Make decoction, and add: 

Acidi muriatici ill xx. 

Syrupi aurantii cort J j. 

M., et sig.: A tablespo^nful in a little water three times 
a day. 

As a heart tonic, the following may be used: 

9 Spir. Ammonii aromatici § iij. 

Ammonii carbonatis 3 j, 

Tr. Cardamomii § j. 

Tr. Nucis vomicae 3 iij. 

M. S.: A teaspoonful in a wineglass of water three 
times a day 

DIETETICS. 

During the entire course of a case of acute 
rheumatism, the diet, both solid and fluid, should be 
simple. Generally speaking, there will be little in- 



— so — 

clination on the part of the patient for solid food, but 
such as may be given should be prepared with special 
care to minimizing nitrogenous elements. Oxidation 
of proteids, the further oxidation and elimination of 
uric acid, should stand out clearly as the object of all 
dietetic arrangements in rheumatic affections. Great 
thirst is usually complained of, and large draughts of 
water may be allowed, cold, but not iced. Advantage 
is taken of the oxidizing properties of water by thus 
permitting its consumption in large quantities, the 
hydrogen tending to the formation of ammonia, the 
oxygen to that of urea. The elimination of uric acid 
is also furthered by the imbibition of water in excess, 
the skin being made to strain off much of the acid in 
the perspiration superinduced by the water. Lemon 
juice, which has been advocated as a specific remedy 
for the disease, may be allowed as freely as it is usu- 
ally urgently demanded by the patient. Lemonade, 
or drinks compounded from citric acid, without much 
sugar being added, may be given as often as asked 
for. The vegetable acids, being converted into car- 
bonates, contribute to the desired oxidation. Milk, 
previously boiled, may be given, on cooling, with lime 
water or Vichy water. If the diet is restricted to this 
simple but nutritious and agreeable combination, until 
the major manifestations subside, perhaps all the re- 
quirements indicated will be met. Chicken or clam 
broths, or vegetable soups with a littte beef flavoring, 
need not be interdicted. If meat broths are given, 




— 31 — 

they should not be used until they have been allowed 
to cool, for the purpose of removing the fat from 
them. 

When convalesence is fully established and tonic 
treatment is instituted, the return to solid food may 
be allowed. It should consist at first of white meat 
and vegetables. Of the latter, asparagus and stewed 
celery are to be recommended. Small quantities of 
fresh fruit may be permitted if desired. Alcohol, in 
any of its forms, should not be allowed, and there 
should be careful avoidance of sweetened drinks and 
saccharine foods. 

TOPICAL APPLICATIONS. 

Of these the name is legion, aud the employment 
for the most part valueless. The physician attending 
a case of acute rheumatism will, however, do well to 
make some provision for such application to the 
affected joints as shall, as far so possible, sooth the 
local suffering by obtunding the cutaneous sensibility, 
and protect the parts from irritating contact with 
air or clothing. This will at least satisfy the de- 
mands, which both patient and friends will assuredly 
make for some form of topical treatment. Probably 
the most efficacious combination is a lotion as follows: 

Q Tr. aconiti radicis 

Tr. arnica aa § ss. 

Chloroformi J j. 

Tr. saponis camphorata J ij. 

M. Sig. — For external use. Apply as directed. 



— 32 — 

Surgeons* lint saturated with this, may be ap- 
plied over the inflammed site and covered in by oiled 
silk; or the lotion may be applied directly to the skin 
surface, and the joint or limb swathed in cotton bat- 
ting. Spongiopilin is a specially prepared, imperme- 
able fabric, of great utility as a vehicle for the various 
lotions or liniments which may suggest themselves. 
This material steeped in hot, strongly alkaline, water, 
such as a saturated solution of sodium bicarbonate, 
and its approximating surface freely sprinkled with 
tincture of opium, when applied is always gratefully 
acknowledged as of soothing effect. 

Blistering the affected sites has been much advo- 
cated. The method is useful in selected cases, for ex- 
ample, when the inflammatory process determines to 
one joint, as it sometimes does, with great effusion, 
threatening the integrity of the articulation, blistering 
with cantharidal collodion over a large portion of the 
swollen area will be found efficacious. 

BATHS. 

These are not to be recommended during the 
acute stage. Indeed the condition of most patients 
would make their employment impracticable without 
absolute cruelty. So soon, however, as the local 
symptoms have subsided sufficiently to permit of it, 
the body should be sponged at intervals with warm 
water containing alcohol, in some form. When prac- 
ticable alkaline and sulphur baths will materially aid 
in restoring suppleness to the stiffened joints. 



I 



— 33 — 

MASSAGE. 

What has been said of baths holds good is 
respect to massage. It will be found valuable after 
the subsidence of all inflammatory symptoms. Want 
of caution in this matter may result in the production 
of a very ugly traumatic arthritis. 

COMPLICATIONS. 

The only complication likely to arise, tending im- 
mediately to a fatal issue, in a case of acute rhema- 
tism is, that of hyperpyrexia with its concomitant 
cerebral manifestations. Such a condition must be 
most promptly met with one remedy. Arrangements 
should be instantly made for placing the patient in a 
bath. The water in which the patient is at first im- 
mersed should be at 90° to 100° F. Cold water or 
ice must then be added until the temperature of the 
water is reduced at least to 60*^ F. If the condition 
will allow of it, the patient may be kept in the bath 
for an hour or more, careful observation being made 
of the pulse, respiration, and temperature. When the 
thermometer indicates the latter has fallen to a 
reasonable point, the patient may be removed from 
the bath, to which recourse must again be had upon 
the recurrence of the hyperpyrexia. While the pa- 
tient is immersed, much of the possible depressive 
effect may be averted by friction of the entire body 
by the hand of the attendants, and the administration 
of aromatic spirits of ammonia, or suitable stimulants. 

3 NN 



M 



— 34 — 

Of course, it is very easy to lay down dogmatically a 
statement that the patient is to be immediately placed 
in a bath, but it is very often impossible to get the 
bath tub. In such a case other action must be 
taken. The patient should be placed stripped upon 
a blanket, the bed being first protected by an India 
rubber gossamer, or some such domestic contrivance. 
A sheet wrung out in warm water should be wrapped 
around the entire body, and the sheet cooled off by 
water of gradually reduced temperature. The body 
of the patient must then be gently dried and wrapped 
in a clean sheet, the underlying wet things being first 
removed. This process must be repeated at such fre- 
quent intervals as will secure a temperature within the 
safety limit, until the tendency to hyperpyrexia is 
controlled. The complications arising about the 
prsecordial region are to be treated on general prin- 
ciples as th<5 various symptoms arise. 



^ 



CHAPTER HI. 

CHRONIC ARTICULAR RHEUMATISM 

DEFINITION. 

A sub-acute disease, chronically persistent, re- 
mittent or intermittent in character, directly, or re- 
motely supervening upon ^cute rheumatism, and 
manifesting itself by pain and certain structural dis^ 
turbances at the site of one or more of the articula- 
tions. 

CAUSATION. 

Without disregard of, or disrespect to, the time- 
honored assertion of possible spontaneity in the 
origin of the disease, it will be perhaps more conven- 
ient to consider chronic articular rheumatism as the 
immediate or remote result of some sharply accen- 
tuated, or perhaps hardly definable, or even unre- 
membered, attack of acute inflammatory rheumatism. 
To accept the oft reiterated opinion that this affection 
of the joints is at times of independent origin is, per- 
haps, yielding to empiricism rather than reason. It 
would seem that either the term chronic rheumatism 
is a misnomer, or the condition should be admitted, 
without exception, as dating its causation from an 
acute rheumatic seizure, however mild or unappre- 
ciated that may have been. While the term chronic 
may signify protracted duration, its general medical 




- 36 - 

use expresses the sub-acute continuation of a past 
acute condition, and it would seem equally consistent 
to speak of a chronic pneumonia, pleurisy, or gonor- 
rhoea, as likely to obtain spontaneously and without 
reference to some initial acute stage. Whether there 
remains in the system some effete, and therefore 
indifferently active, morbific principle, sufficiently 
typical of the initial poison to continue its selective 
action on those joints which have become a locus 
minoris resistenttce^ or whether the disturbance to the 
structural components of the articulations affected at 
the time of the acute process was of such a character 
as to render ijtjeffectual reparative efforts on the part 
of an impaired constitution, are propositions which 
may each contain a modicum of fact, but both of 
which are unprovable except upon hypothetical bases. 
If there exists on the part of a patient hereditary 
rheumatic dyscrasia, it seems reasonable to assume 
such a one as more prone to suffer from chronic 
sequelae after acute attack. The causes which appear 
to invariably incite into action or aggravate into 
severity this painful affection, are pretty well repre- 
sented by the same list of inaccuracies in living and 
imprudent exposures which conduce to predisposition 
tOj or actively excite, an acute inflammatory attack. 
Damp and cold, wind and draughts, getting wet^ 
living or sleeping in damp houses or apartments, are 
influences which prove active causes for determining^ 
the disease to its worst phases. Unsuitable climates,, 



— 37 — 

and ever varying atmospheric surroundings, are likely 
to specially effect those chronically rheumatic. 

SYMPTOMATOLOGY, 

If the chronic condition supervenes upon a well 
marked acute attack, there will probably be imperfect 
subsidence of the enlargement about one or more of 
the joints. There will remain some impairment of 
function at these sites, with intermittent, remittent, 
protracted, or persistent, tenderness or pain propor- 
tionate to the presence or absence of the already 
enumerated exciting influences, and the exhibition of 
mitigating remedies from time to time. During wet 
and cold weather, or especially when it is both cold 
and wet, the chronically affected joints are generally 
the most painful. There may be some swelling and 
local tenderness if the attack is severe. Passive 
motion will often elicit pseudo-crepitation. Some pa 
tients remain free during long intervals, but when an 
adequate, though perhaps undeterminable cause, in- 
duces a sub-inflammatory seizure, the symptoms will 
always be referred to one or more of the previously 
affected joints. 

Attacks of this character may be associated with 
febrile symptoms and some constitutional disturbance. 
If the initial point of departure has not been well de- 
fined, the symptoms will for a time be referred to 
those of mere painful sensation about the joints, the 
structural changes coming on insidiously. In pro- 



- 38- 

portion to the extent of this implication will be the 
nodosity around the joints and their functional im- 
pairment. From disuse and favoring the affected 
parts, there is often marked muscular atrophy which 
throws the articulations into special prominence. 

COURSE AND TERMINATION. 

This malady once well established runs a some- 
what uneventful course. The worst cases are asso- 
ciated with ever increasing deformity and interfer- 
ence with the excursions of the joints, to the point of 
immobility. It is a condition considered as but little 
amenable to remedial measures, though the author 
hopes to somewhat modify this opinion. Whea a 
case is left to run an uninterrupted and unfavorable 
course, life becomes a burden, and though the disease 
is never fatal, the condition, by depriving the patient of 
rest, and inhibiting ordinary avocations and pleasures^ 
embitters, and probably shortens life. 

PATHOLOGY. 

The appearances of the rheumatic joint in a 
chronic case, do not always, on post-mortem inspec- 
tion, coincide in extent with the degree of disturb- 
ance experienced during life. The changes in a 
typical case are such as mark chronic inflammatory 
irritation. Thickening and cloudiness of the synovial 
membrane, with hypertrophy and increased vascularity 
of the villous processes, exist with a flabby, relaxed^ 




— 39 — 

frayed condition of the cartilage, and possibly fatty 
changes. In the more pronounced types, the fascia, 
the aponeurotic sheaths of the muscles, the fibrous 
envelopes of the nerves, and the periosteum, will be 
found undergoing changes. The fluid in and about 
the joint is usually thick, turbid, and contains broken 
down tissue and oil globules. The erosions of the 
articular cartilages, and the slow changes in the 
bone, with the inflammatory adhesions generally, will 
be found to have so limited motion in the joints as to 
have produced a condition practically analogous to 
complete anchylosis. 

DIAGNOSIS. 

The clinical history of the case pointing usually 
to a previous acute attack, and the fact that the pa- 
tient is peculiarly susceptible to any variations of 
atmosphere and temperature, will generally serve to 
establish a diagnosis. Arthritis deformans can be 
excluded by reference to the above points, and by the 
absence of a very characteristic deformity, common 
to the latter, and by a certain limitation as to num- 
ber, and want of symmetrical selection, of the joints 
involved in chronic rheumatism. Care must be taken 
to exclude also traumatic and tuberculous joint 
troubles, and the articular neuroses. This can be cer- 
tainly done by noting the disproportion between the 
subjective and objective symptoms, and the probable 
existence of anaesthesia or hyperaesthesia within the 
affected area in the neurotic or neuritic cases. 



CHAPTER IV. 

TREATMENT OF CHRONIC RHEUMATISM. 
If the physician of to-day could command the 

• 

routine of a scientifically prescribed course of treat- 
ment in the cases of chronic rheumatism which come 
from time to time under his observation, it is probable 
that many results would be attained far more brilliant 
and satisfactory than ordinarily achieved. Still, a 
well marked case is at best difficult of management, 
and the local changes often such as are impossible of 
restitution. Nevertheless, much may be, and is done- 
Paramount as a factor essential to the ultimate suc- 
cess of treatment, is the entire submission of the pa- 
tient to certain restrictions in the matter of diet. It 
is here that the physician is likely to come athwart 
his greatest difficulty. Prejudices, perhaps of his 
own, or on the part of the patient and friends, will be 
likely to prove serious obstacles. If the theory be 
accepted that to the presence in excess of uric acid 
from sub-oxidation of nitrogenous food-stuffs and 
mal-assimilation is due the train of symptoms consti- 
tuting rheumatism, then it should need little argument 
to establish the axiom that abstention, so far as pos- 
sible, from a highly nitrogenous diet, is desirable as 
the first step in the direction of minimizing a ten- 
dency to failure in oxidation to the point of urea 
formation. This means that meat should be abstained 




— 41 — 

from absolutely by the patient who earnestly intends 
to get the best possible results out of systematized 
treatment in a case of chronic rheumatism. It is per- 
haps not too much to assert that permanent benefit 
can never be assured by tlie physician, or hoped for 
by the patient, until this point is yielded. Beef, the 
richest of all in nitrogenous constituents; mutton, 
and pork, cannot be allowed. Too much meat is 
eaten by the people of this country. It certainly is 
not necessary to bone and sinew. The brawny High- 
lander eats Scotch oatmeal, and reads about meat. 
The nervous, dyspeptic American, who eats meat 
three times a day, is seldom able to write himself 
down a perfectly well man. Exaggerating this un- 
necessary use of nitrogenous food, is the pernicious 
method known as the Salisbury diet, under which the 
patients are directed to eat as much meat as they 
possibly can. The result is, that oxidation of the 
super-abundant food, if accomplished at all, is at the 
expense of the body tissues, and the effect of the over- 
stimulation, imperfect oxidation and non-assimilation, 
is a general loss of muscle and failure in tone. Hap- 
pily, the prohibition of the dark meats mentioned is 
not so terrible a privation after all; and if the too 
kind friends of the patient will withdraw their solici- 
tude, and do their share in providing the many suc- 
culent and withal nourishing substitutes, the invalid's 
chances will be much improved. It is a common 
plaint of the patients, otherwise willing to follow 



— 4a — 

rules, that they find abstention from meat difficult 
and well nigh impossible when visiting or dining out. 
The diet of a patient chronically rheumatic, but with 
fair general health, need not be restricted save in the 
matter of meats, saccharine* foods, and alcoholic stim- 
ulants. A farinacious diet is not contra-indicated. 
If the digestion is in good order, a little well-cooked 
roasted or boiled veal may be occasionally allowed. 
Moderation in table indulgences should be rigidly en- 
joined. When the patient is amenable to suggestion, 
and in a position to carry out a course of treatment, it 
will be desirable to arrange the course upon the fol- 
lowing lines: 

' Cholagogue . 
Alkaline. 
Constitutional. •• Analgesic. 

j Tonics. 
Medicinal -{ [ Mineral waters. 

( Massage. 
Local. \ Liniments. 

( Electricity. 

CHOLAGOGUES. 

It is of the first importance that persistent atten- 
tion be paid to the emunctories. Mild, but oft re- 
peated stimulation to the liver must be insured; and 
this may be accomplished by the aid of any carefully 
chosen cathartic. Attention to this point should form 
the initial step in the treatment. It is not enough 
that the patient, in answer to the hackneyed query as 
to the state of the bowels, replies that they are all 




— 43 — 

right The following combination is suggested as of 
value, and one which can be given for it long period. 

9 Euonymm 

Leptandrin 

PodophylliiL. 

Ext. aloes tfoc 

PiL liffdragyri 

Czt. hyoscyamus ii& gr. v. 

if. Div. in pil. (argent.) No. X. 

Sig. One to two pills every night, or every alternate 
night, as indicated. 

Or the following purely vegetable pill may be em- 
ployed with satisfaction: 

9 Euonymin gr. xz. 

Fl. ezt. cascara 3 v. 

M. Div. in gelatin capsules No. X. 
S. One capsule every night. 

ALKALIES. 

Careful examination should be made of the pa- 
tient's urine. The existence of serious renal compli- 
cations being excluded, such alkalies as are well borne 
by the stomach and serve to insure slightly alkaline, 
or at least neutral, reaction of the urine, should be ex- 
hibited throughout the whole course of treatment. It 
is to be borne in mind that the alkalinity of the blood 
is less than normal in chronically rheumatic subjects. 
Two grains of euonymin and one drachm of bi-carb- 
onate of soda, given in a little water after every meal, 
will be efficient. In the event of any pronounced 



— 44 — 

acidity, the stronger alkaline mixture indicated for 
acute rheumatism, may be used for a time. 

The salicylate of lithium, or the bromide of 
lithium, may be made full use of in the medicinal 
treatment of this affection. Given systematically for 
a long period, in conjunction with appropriate dietetic 
observances, they will oftentimes give the happiest 
results. The former of these lithium salts, in doses 
of five to eight grains three times a day, may be given 
indefinitely without the least disturbance of the diges- 
tive functions. 

Salol, and the salicylate of soda, are of little 
value. They disagree with the stomach, and are of 
only transient effect. 

ANALGESICS. 

The policy of promptly administering some form 
of medication, both internal and local, for the relief 
of the pain, which is frequently severe, need not be 
enlarged upon. Morphine, except imperatively indi- 
cated, must be withheld. The writer would recom- 
mend antipyrin, say in five-grain doses. Phenacetin 
may be used with advantage to allay pain, and 
is perfectly harmless; ten grains, three times a 
day, will be found sufficient in almost every instance. 
Sulphonal, though it possesses but slight analgesic 
properties, may be given in twenty- to thirty-grain 
doses as an hypnotic. It is, perhaps, contraindicated 
in the presence of gastrectasis, gastric congestion, or 




— 45 — 

chronic gastritis, on account of its slow solubility, 
though this may be to a great extent overcome, and 
its absorption and effect hastened, by the addition of 
a little sugar-of-milk to the sulphonal, and a thorough 
trituration of the combined powder. 

TONICS. 

While it is not desirable to insist on more medi- 
cine than will meet the requirements, a good tonic 
will probably be advisable after activity of the liver is 
established, and the patient is fairly under control of 
the alkalies. Any tonic mixture or preparation may 
be chosen which seems specially suitable. An ex- 
tremely useful pill, which may be taken for a length 
of time, is compounded as follows: 

9 Acidi arseniosum gr. i. 

Strychnine sulph gr. i. 

Ferri sulph 3 i. 

Quiaia sulph 3 ss. 

Lactopeptin 31. 

M. DIv. in capsules. No. xxx. 

Sig. : One pill three times a day, before each meal. 

MINERAL WATERS. 

These may be partaken of freely, and may be 
made the substitutes for water, and other drinks, 
during treatment. Their name is legion. The author 
would suggest that the Londonderry lithia water be 
used, and that it be taken by the tumblerful, three 
times a day. If some water with slight aperient 



-46 - 

property is desired, it may be well to use Rubinat, or 
Villacabras. A wine-glass or claret-glass full of either 
of these, which contain a generous percentage of 
sodium sulphate, taken in the morning, and followed 
in half an hour by a cup of hot tea or coffee, will be 
efficacious, and is advisable if a cathartic pill has 
been taken the preceding night. 

LOCAL TREATMENT. 

If any practical benefit is derivable from mass- 
age, and few who have seen it scientifically admin- 
istered will deny its therapeutic rank, it will certainly 
be of utility in chronic rheumatism. Mechano- 
therapy may be advocated in this disease upon the 
assumption that its physiological effect is to increase 
the flow of blood to the parts manipulated, the 
induced activity of the circulation, removing accumu- 
lations of waste tissue and morbid deposits, the 
retention of which gives rise to pain and disturbance 
of function. Theoretically, massage about rheumatic 
joints in which deposits have occured, should cause 
reabsorption of such deposits and the separation of 
adhesions in sheathes of tendons, and in the joints, 
by grinding away the intra-arthritic and surrounding 
accretions. 

There is really no therapeutic value to any one 
of the innumerable liniments and lotions by virtue of 
which they can effect restorative changes in a chronic 
rheumatically affected joint. 



— 47 — 

Some absorption of anodynes may take place and 
lessen pain by acting on the peripheral nerves, but if 
any real good Comes by the use of such remedies, it 
is directly by reason of the associated friction in ap- 
plying them. However, liniments will be demanded, 
and must be given, the physician taking care that 
they are applied with some approach to massage 
movements. Better still, if the icase can be put into 
the hands of an experienced masseur for this part of 
the treatment. 

A liniment of the following oils may be pre- 
scribed for use during manipulation: 

9 Ol. sesami | viij. 

Ol. succicini § j . 

Ol. thymi 3ij. 

Ol. carri 3 ss. 

Ol. rosae Vij, 

Alkanet q. s. 

The following ointment has been found of con- 
siderable service in effecting the absorption of recent 
deposits in and around the joints: 

9 lodinii 

Potass lodidi UK gr. xl. 

Ungt. Aq. Rosae | i. 

M. Ft. ungt. 

S. To be nibbed into the skin over the enlarged 
joints every night. 

The Swedish movements are also serviceable as 
promoting increase of muscular nutrition. When 



- 48 - 

wasting of the muscular structures exists/ and there is 
a generally lowered functional vitality in the limbs 
from disease, electricity, both galvanic and faradic, 
may be advantageously employed. Any bungling 
attempt with the faradic current, such as shifting the 
electrode aimlessly over the arm or leg, and produc- 
ing violent spasms, is worthless. The motor points 
should be studied, and a mild faradic current be 
brought to bear sufficiently often to give each set of 
muscles gentle exercise at every stance. 

It is a question whether baths, vaunted though 
they have been, are of general utility in chronic rheu- 
matism. Some cases, it is true, seem to magically 
respond to a course of bathing at one or the other of 
the various Springs, but it is a question whether the 
change of air and habit are not after all the more 
potent factors. Sulphur baths may be tried. If any 
form of bathing produces a loss of tone, it should be 
discontinued. 

Flannels or merinos, to be worn next to the skin, 
should be insisted upon, and they should never be 
discontinued except perhaps during the hottest part 
of summer. Care should be taken to examine care- 
fully into the hygienic entourage of the patient. When 
the course of treatment is well instituted, and the de- 
tails to be observed are thoroughly understood by 
patient and friends, a change of air may be sug- 
gested. The necessity of steadfast adherence to the 
lines of the treatment for a period of many months, 
must be firmly insisted upon as a sine qua non. 



k 



— 49 — 

Treatment, carried out intelligently upon the 
basis of the foregoing suggestions, will be found pro- 
phylactic of the occurrence of many of the com- 
plications to which rheumatic people seem specially 
prone, such for instance as follicular tonsilitis, bron- 
chitis, and pharyngitis. The condition of imperfect 
assimilation, which is always present, frequently gives 
rise to various troublesome forms of eczema, psoriasis 
or other skin manifestations, these symptoms yielding 
gracefully to persistent and profound alkalinization. 

4 NN 



^ ^ J J J 




CHAPTER V. 

RHEUMATOID ARTHRITIS. 
{Arthritis Deformans,) 

DEFINITION. 

A disease of obscure origin and insidious ap- 
proach, characterized by progressive changes in the 
structural components of the joints, with resultant 
permanent deformity. 

CAUSATION. 

Here it is better to admit that the acumen of the 
scientific medical investigator is at fault. Perhaps 
this frankness would be both graceful and accurate in 
respect to the whole series of joint affections, yclept 
rheumatic and gouty, but it is excusable, and perhaps 
in the direct line of progress, to resort to hypotheses 
for temporarily bridging the chasm between ignorance 
and truth. But this same rheumatoid arthritis has 
come in for more than its share of conflicting sur- 
mises and ambiguous pseudonyms. The influences 
which are stated as calculated to produce the disease 
in its incipiency, are so numerous as to demonstrate 
pretty conclusively that they cannot all be correct. It 
is said to be essentially a disease of the poorer classes, 
but this may be urged of most diseases which do not 
date their origin from excesses in which the poor can- 




^ WW 



_ 51 ~ 

not indulge. Childhood and youth are tolerably ex- 
empt from it, the tendency being the greatest after the 
thirtieth year. Women are the more frequently sub- 
ject to it, and the period of the climacteric favors its 
development. Then again its occurrence is ascribed 
to such causes as traumatism, damp and cold, a tuber- 
culous diathesis, frequent pregnancies, poverty and 
bad hygienic surroundings, moral influences, such as 
nervous depression from anxiety and grief, protracted 
lactation, poor living, and so on, ad infimtum\ and 
very much ad libitum^ may these antitheses be ampli- 
fied. The more modern assumption that pathological 
processes within the central nervous system are 
responsible for the principal manifestation, has re- 
ceived much attention. Among the arguments urged 
in support of this theory is the fact of the disease fre- 
quently dating from a period of known and well accen- 
tuated nervous disturbance. 

SYMPTOMATOLOGY. 

It seems pretty sharply defined that in an indi- 
vidual in whom the predisposition exists to take on 
this disease of the joints, it only requires some injury 
or prolonged irritation directed to any particular joint 
to insure the appearance of the characteristic changes 
in that site. Some swelling may be noticed, with 
more or less pain referred to regional nerve-tracks. 
Subsidence of symptoms will be followed by recur- 
rence, and the involvement of other joints or groups 



— 52 — 

of joints; these will be seen to be slowly enlarging, 
and it will be noticed that a certain indefinable stiff- 
ness impedes their movements, and that this is 
especially so after retaining one position for a time, 
the joints requiring use to produce freedom of action. 
Some crepitation is present, due either to apposition 
of denuded bony surfaces in the joint, or from move- 
ment of tendons within partly ossified sheaths. Atro- 
phy, more than commensurate with the enforced dis- 
use of the muscles, is a marked feature; and this, 
with the gradual disappearance of the subcutaneous 
fat, gives to the affected limb a wasted look. The 
joints of the hand seem to be points of early selec- 
tion. Distortion of the metacarpal extremities of the 
phalanges is caused by the formation of large nodules. 
These accretions or exostoses, and the contractions of 
the tendons, at length effect a series of luxations; the 
fingers are drawn into rigid flexion, lapping each over 
the other; characteristic deformities and anchyloses 
accompany corresponding changes in the articula- 
tions, and in the worst cases all ability to move is lost. 

PATHOLOGY. 

The joints in which the disease first manifests 
itself are said to be in a condition of hydrops articuli^ 
and to contain in their cavities an excess of clear syno- 
vial fluid, while the walls of the joints are thickened, 
and the various flocculi are increased in size and 
number, and present a more or less congested ap- 



— 53 — 

pearance. Later on will be found quantities of 
new bone thrown out in nodular masses around the 
margin of the articulation, and occasionally osseous 
formations in the capsular ligaments. The processes 
which involve the cartilages are supposed to com- 
mence by some irritative proliferation of cartilage 
cells, producing a state of softness and overgrowth. 
This softening, it is thought, tends to a wasting of 
the portions which have to sustain pressure or attri- 
tion. The soft overgrowth bulges as an irregular rim 
around the joint, and there ossifies. This theory has 
been negatived in favor of another which favors the 
supposition that the new bone formation results from 
the continuous irritation to the periosteum, and that 
it is the direct outcome of chronic inflammation, sim- 
ulating the exostoses of other bone diseases. The 
articular surfaces of the larger bones which have lost 
by erosion their cartilaginous coverings, become poU 
ished by impact and friction. 




CHAPTER VI. 

TREATMENT OF RHEUMATOID ARTHRITIS 

TREATMENT. 

It has been well said that treatment of this dis- 
ease, to be of any value, should be begun £bi1j 
and must be active. By active treatment is to be 
understood the prompt direction of therapeutic agents 
to all the known or assumed failures in the economy 
of the patient which hiay be promoting disturbance 
of the general physiological equilibrium. When this 
is done, and done well, the constitution will be in the 
best possible condition to respond to the action of a 
specific remedy, if such exists. If the local changes 
are not already marked, careful treatment will cer- 
tainly give brilliant results. If the structural deform- 
ities are pronounced, surgical interference may be of 
some benefit, while systematic treatment may arrest 
progress and ameliorate symptoms. After a certain 
point has been reached, the condition is permanent^ 
and interference, with hope of restitution, futile. 
Before this desperate stage is arrived at, however, 
much can be done. Therefore it is wise to bring the 
patient's system at once within the action of such 
drugs as will assist the elimination of effete material, 
and ioaugurate a dietary sufficiently non-nitrogenous 
to insure maximum oxidation* 

DariE meats must be forbidden and so must 




— 55 — 

saccharine food and alcoholic beverages. Beyond 
this no restrictions are necessary if moderation in all 
things is exercised. To lay out a plan of diet is often 
to harass and confuse, and at once conflict with the 
possibilities of the patient's means and surroundings. 
But the broad principle of abstention from meat, 
sugars, and alcohol, covers the ground, leaving fish, 
fowl, eggs, farinacious food, vegetables and fruits, 
from, which culinary ingenuity can elaborate an ap- 
petizing as well as nutritious diet in ample variety. 
Care should then be taken to exhibit suitable chola- 
gogues and secure proper action of the liver. The 
author has found Metcalf's Liquor Pancreaticus, one 
to two teaspoonsful in water with each meal, efifective 
in keeping the stomach in good condition. Catharsis 
may be determined by the use of the eunonymin pill 
at night, and alkalinization by the use of the soda 
and eunonymin powder after meals. Both these pre- 
scriptions may be found in the treatment of chronic 
rheumatism. 

Without losing sight of the fact that dogmatic 
statements as to the specific value of any particular 
drug may weaken the position of him who makes it, the 
writer feels justified in urging the potency of arsenic in 
all cases of rheumatoid arthritis which are still amen- 
able to treatment. In what way its curative agency ijs 
determined, is a bone over which all therapeutists still 
contend. Its action may be on the nutritive function 
by promotion of constructive metamorphoses, or it 



_S6- 

may have a selective action on the central and trophic 
nervous systems. As with mercury in syphitis, so with 
arsenic in rheumatoid arthritis, we use them because 
they are found to have a certain therapeutic efficacy, 
and can only generalize and theorize as to the why and 
wherefore until such time as therapy and physiology are 
more exact sciences. Arsenic seems to exert some 
special action on the joints; there is much restoration 
of function, pain is lessened, and there is a gradual 
diminution of the swelling, while the progress of the 
disease is arrested. Therefore the writer would urge 
its use. The literature of therapeutic investigation is 
rich in facts and theories as to the action of the 
drug. It seems pretty clear that it must be the special 
care of t^e physician prescribing it to note the effects 
of its exhibition in every new case, and throughout its 
routine use. There appear to be the most diametri- 
cally opposed views as to the method of commencing 
a course of arsenical medication. Authors of univer- 
sal reputation as leaders in therapeutical investiga- 
tions, and the recognized formulators of rules for the 
guidance of lesser lights, differing widely. One 
dictates that the drug should be commenced in 
large doses, that the quantity should be regularly 
reduced, and that thereby liability to arsenical poison- 
ing is avoided. Another states that by the use of 
frequent small doses, the irritating symptoms may 
be escaped, and the constitutional effect of arsenic 
obtained. Yet, again it is laid down, that it is a great 



— 57 — 

error to order it in gradually increasing doses. There 
is no doubt that these deductions were honestly made 
after careful experiments, but when the various opin- 
ions are fused, the resultant is an intangibility. This 
may be emphasized, that arsenic is a drug which is 
likely to make evident its presence in the system by 
certain well known manifestations, as irritation and 
congestion of the conjunctivae, puffiness of the eye- 
lids, gastro-intestinal trouble, and so on. That when 
it does so, it is imperative to so adjust the dosage 
that these symptoms are abated, or to temporarily 
discontinue the drug. That in view of idiosyncracies 
existing, it is well to commence with what is recognized 
as a medium dose. If Fowler's solution is used, then 
five drops, for an adult, three times a day, is usually 
borne without trouble, and will, as rule, soon result in 
some slight indications of physiological disturbance. 

After a time the system becomes accustomed to 
its use, and the dose may be increased, by half-drops, 
until decided symptoms of arsenical poisoning appear, 
when the further increase is stopped, and the same 
dose maintained for some time, say several weeks or 
months; then the dose may be diminished, or the use 
of the drug temporarily suspended. 

This latter method, though the simpler, is proba- 
bly not the most scientific. Arsenic is so rapidly elim- 
inated from the system, that to abandon its use for a 
fortnight is simply to give the arthritis a chance to 
increase, and when the drug is again taken up, the 




-58- 

process of surcharging the system and regaining lost 
ground must be gone through. By carefully watch- 
ing the indications, and by the timely use of lazativeSy 
the dosage may be easily adjusted so that this invalu^ 
able drug may be utilized indefinitely and with de- 
cided benefit, unless there co-exists any acute inflam- 
matory or other condition contra-indicating its use. If 
arsenious acid is preferred, the dose is one thirtieth 
to one- tenth of a grain, subject to the modifications 
and precautions already set forth. This may be given 
in tablet form, well triturated with sugar-of-milk, and 
taken after meals. Commence with the smaller dose, 
and gradually work up to the largest daily amount 
which the patient can continue taking without positive 
discomfort from the characteristic action of the rem- 
edy. 

Careful study of the effects of the drug in each 
case, will enable its administration to be so graded 
that a tolerance can be established, a point to be 
much desired, in order to get from its employment 
the maximum benefit. When it is remembered to 
what enormous doses the arsenicophagi become 
habituated, failure in its medicinal administration 
argues the want of ability to employ it scientifically. 

As general debility is frequently a concomitant 
of rheumatoid arthritis, it is well to use some form of 
tonic mixture, or pill, as soon as the emunctories are 
in working order. The mineral waters may be freely 
used. There is a water which seems of value and 




— 59 — 

specially applicable, known as the Plummer Bromine 
Arsenic water. It xnajr be taken as a table drink to 
the extent of a quart a day. 

Pain may be combated with any of the modem 
analgesics except morphine, which must.be only used 
when the suffering is unsupportable. Antipyrin and 
phenacetin will often be found efficient, the latter for 
its hypnotic effect only. 

Local applications in the shape of lotions and 
liniments are of no value, except negatively through 
the use of the manipulations and passive motion inci- 
dental to their employment. 

Electricity, in any of its forms, may be considered 
worthless in this disease. 

Iodine ointment, such as advised under the treat- 
ment of chronic articular rheumatism, is of consider- 
able value, especially in the more recent cases. 

The use of medicated baths, in this disease, is 
probably valueless, although there are some who be- 
lieve still in the efficacy of the sulphur bath. 

General massage, and the systematic movements 
of all the joints, as by the Swedish method, are 
among the most valuable adjuncts to the systematic 
treatment, and should be faithfully pursued over an 
extended period, from two to six times a week, and 
used for half an hour or an hour at each application. 



CHAPTER VIL 

GOUT. 

DEFINITION. 

A constitutional disease manifesting itself at in- 
tervals by paroxysms of intense pain at the sites of 
the lesser joints, to which are determined deposits of 
urates. The classical point of selection is usually the 
first metatarso-phalangeal articulation in one or both 
feet 

" CAUSATION. 

The exact molecular changes determining an 
acute attack of gout, like many other apparent 
failures on the part of the economy to project its 
chemical reactions to the point of physiological per- 
perfection, are still within the debatable domain of 
the medical theorist But the less scientifically de- 
fined influences which conduce to those disturbances, 
prone to culminate by a seizure, in a person assumed 
for the sake of argument as free from all hereditary 
gouty taint, are more readily definable. The early 
acquisition of wealth renders its application to per- 
sonal luxury only too probable, and if this take the 
form of indulgence in eating and drinking, there will 
be slowly but surely established at least a predis- 
position to gout, for it is essentially a diner's disease. 

It has been truly urged that lack of exercise 
with indulgence in the pleasures of the table promote 




— 6i — 

the dyscrasia, but it is also true that the English fox- 
hunting squire who passed his existence for the most 
part in the open air, but who also persisted in drink- 
ing a couple of bottles of port wine with a prodigious 
dinner, became at length the monumental exponent 
of the agonies of typical gout 

It has been well termed the spectre and scourge 
of the rich and sensual. The theory has been ad- 
vanced that deficient oxidation acts as a cause. This 
is doubtless true in part. It must be, however, re- 
membered that the wealthy are the gouty, and that 
this class, indolent though it may be, can and does 
avail itself of far more oxygen than the inhabitants 
of over-crowded dwellings and workrooms. If the 
sub-oxidation theory is tenable, then the failure may 
be presumed to arise from the constant surcharging 
of the system, by those who are over-indulgent, with 
such highly nitrogenized material, plus alcohol, as, by 
its quantity and quality, renders a normal supply of 
oxygen inadequate to perfect physiological adapta- 
tion or elimination. 

The etiology has been humorously emphasized 
by a classic adage, the pith of which is expressed in 
the doggerel couplet: 

** Vinum der Vater, Coena die Mutter, 
Venus die Hebamm' machen das Podagram." 

It is doubtful whether the last named lady is 
fairly entitled to any blame for this disease, and she 
is already sufficiently overwhelmed by reproach. 



— 6t — 

If the tendenqr to an acate attack is w^\ 
established, the ezdtiiig catises detennining a paroz- 
jsm are quite namerons. Any special gonnand 
izing, excessive potations, fits of anger or grief, 
changes in the weather, mental strain, or a dyspeptic 
attack, are ripe exciting caosea It is thought that 
the immediate result is brought aboat by failure in 
the excretive power of the kidneys. If to the cate- 
gory of known originating causes directly within in- 
dividual control, there is added the universally ad- 
mitted tendency to heredity, the sum of chances 
against escape is pretty well made up. Gout is a dis- 
ease which once established in a well-to-do family, 
"sticketh closer than a brother." It is very prevalent in 
England where wealth, and the possibility of self- 
indulgence, with indolence, obtain more than in any 
other country. In the United States its appearance 
keeps pace in frequency with the ability and inclina- 
tion on the part of the wealthy to abandon the game 
of gain, and emulate the habits of the trans-Atlantic 
gouty. It goes without saying that men are more liable 
to gout than women. When the disease is inherited it 
sometimes shows itself in the young. Properly culti 
vated it may appear any time after the thirtieth year. 

It has been both demonstrated and denied that 
workers in lead are prone to the development of typi- 
cal gout. The theory is as much shrouded by uncer- 
tainty as ever, and it will probably be found that the 
few lead workers who are attacked with gout are 




-63- 

those in whom the dyscrasia is established by careless 
living and more or less pronounced alcoholism, ac- 
centuated by the well known deleterious systematic 
influence of the lead. 



SYMPTOMATOLOGY. 



If to the inherited dyscrasia, or the induced pre 
disposition, there is added an exciting cause, the result 
will be an acute attack of typical gout. The pro- 
dromata are vague, and until after repeated seizures 
cannot be well defined by the patient. He is gener- 
ally to some extent out of sorts, irritable, low spirited, 
sleepless, nervous, and constipated; there may be 
some mental hebetude, a feeling of weariness in the 
limbs, febrile or chilly sensations, and perhaps a pre- 
monitory twinge or two referred to the base of the 
great toe. All these introductory warnings may be 
absent, and exhilaration be experienced, at least it is 
so laid down in the books. The paroxysm generally 
commences at what is supposed to be the period of 
minimum vitality, soon after midnight, or during the 
earlier hours of the morning. An intense pain com- 
mences in the ball of the great toe, which is burning, 
crushing, boring, or grinding in character, and ap- 
parently as unbearable as it is indescribable. Hand- 
ling or motion of the affected part adds to the suffer- 
ing. There is great thirst, the thermometer indicates 
more or less pyrexia, and the pulse is full and bound- 
ing. The skin around the toe joint becomes tense 



— 64 — 

from rapid swelling of the parts beneath, and is hot, 
red, and glazed, with marked venous distension. In 
a few hours there is a gradual subsidence of the 
violent symptoms, and probably sweating, followed 
by a sense of general relief, and sleep. 

This history is likely to repeat itself nightly for a 
period of three days to a week or more, the joint re- 
maining painful to the touch, and the toe, or possibly 
the foot and leg, being more or less swollen and oede- 
matous for some time longer. As the painful symp- 
toms abate and the swelling subsides, there is des- 
quamation of the skin around the previously inflamed 
area, that replacing it being of normal appearance. 
This stiffness gradually wears away, and the joint re- 
gains its utility, but not its physiological integrity. 
There is some constitutional disturbance during the 
attack, generally indicated by loss of appetite, con- 
stipation, coated tongue, and high-colored and scanty 
urine, which deposits large quantities of solid material 
on cooling. Urination causes more or less scalding. 

The foregoing brief sketch of a case of typical 
podagra covers only part of a wide range of facts 
and fancies with which the literature of the subject 
abounds. Much of this bears testimony to the care- 
ful consideration and accurate observation which 
have been given to the disease. There has, however, 
crept m much that bewilders; we have many gouty 
diseases which are not gout, and much gout appear- 
mg in the form of other diseases; and the terms 



^ 



. -65- 

regular, typical, normal, acute, true, irregular, anoma- 
lous, latent, chronic, atonic, internal, misplaced, typi- 
cal, and suppressed, gout, give ample opportunity for 
disguising uncertainty in opinion by pseudo-scientific 
ambiguity. 

When an acute gouty inflammation, say of the 
toe, suddenly aborts, and the process or an allied com- 
plication simultaneously manifests itself in the abdom- 
inal viscera, kidneys, heart or head, the patient, though 
perhaps at first in no imminently critical condition, 
has unquestionably entered upon a more serious 
phase of the disease from prognostic standpoint. The 
theory so long maintained that actual metastasis of 
the acute process takes place, has been abandoned, or 
is at least strenuously opposed, and the terms retro- 
cedent and suppressed gout are dropped from the 
redundant nomenclature of the disease. The physi- 
cian who has to deal with a chronically gouty patient 
is, however, likely in the course of the acute seizures, 
to meet with the manifestations indicated. The stom- 
ach may become the seat of various disturbances of 
the nature of acute gastritis or gastralgia. Upon 
subsidence of such an attack there is likely to super- 
vene a train of dyspeptic s)rmptoms of the most ag- 
gravated character. If the heart be attacked there 
will be symptoms referred to marked circulatory dis- 
turbances, and difficulty of breathing, with a sense of 
precordial oppression. The gravity of these phases, 
or complications, depends upon their intensity and the 



5 NN 



— 66 — 

extent of the pathological deterioration to which the 
patient's tissues have already been subjected. 

COURSE AND TERMINATION. 

It is more than likely that when the general 
health is restored after a first attack, the habit which 
induced the condition making its occurrence possible 
will be assiduously resumed. If this is done, a second 
seizure will probably come on within a year, and so 
the changes will be rung upon over-indulgence and 
gout. The intervals between the gouty seizures grow 
small by degrees and painfully less, and each attack 
leaves its local and constitutional impress, and in the 
aggregate determines a condition known as chronic 
gout, in which there are constantly present some 
manifestations of the disease and its induced sequelae. 
The paroxysms, instead of being annual or bien- 
nial, are eventually of greater frequency and of less 
intensity but longer duration. Instead of subsidence 
of the associated swelling, there remains a lumpiness 
about the joints afifected, these nodular resultants of 
the accretions at the joints being known as tophi. 
These deposits also occur in the helices of the ears and 
at other cartilaginous sites. The joints become gener- 
ally disorganized, and there may be much consequent 
deformity and impairment of motion. As the disease 
progresses, the gouty cachexia is established, the con- 
stitutional symptoms attain prominence, and embrace 
ever}* possible functional derangement of important 




-67 - 

organs and viscera. If it is admitted, on the one 
hand, that gout does not directly cause death, it can- 
not be denied that such issue is hastened by the aggres- 
sive and progressive influences of inherited or induced 
diathesis and associated sequelae. 

PATHOLOGY. 

So far as can be ascertained, the primary patho- 
logical change is the presence in the blood, transuded 
and exuded fluids, cartilages, periosteum, synovial 
fringes, and fibrous structures of the joints, of uric acid 
in excess, chiefly in the form of urate of soda. If a joint 
is examined which has been subjected to an acute at- 
tack of gout, its articular surfaces will be found cov- 
ered with an apparently amorphous substance, which, 
upon microscopical inspection, is found to be com- 
posed of radiating acicular crystals of urate of soda. 
This incrustation, when increased by continuous de- 
posit, becomes a factor in producing degenerative 
changes, erosions, and destruction of the articular 
structures. The source of irritation producing the 
above changes will determine inflammatory processes, 
which become chronic, in blood vessels and organs. 
The kidney is especially affected by these deposits of 
urates within its tubules, parenchyma, and pelvis. 



CHAPTER VIH. ^ 

TREATMENT OF GOUT. 

Gout, in its kaleideoscopic manifestations, pre- 
sents a most interesting field of action to the thera- 
peutist. Probably there is no pronounced disease 
which would yield more gracefully to the practice of 
medicine than gout, but for one generally insuperable 
obstacle, yclept, the patient. Covering the ground 
as a general proposition, it has been already laid 
down that gout, except that form induced by lead or 
hereditary predisposition, is essentially an outcome of 
dietetic excesses. The habits of self-indulgence^ 
which have become ingrained, will tend to render 
nugatory, to a great extent, the effects of valuable 
advice, and therapeutical endeavor. Venter non habet 
auresy therefore too much must not be expected. 
Formulate a course of treatment for gout which^ 
while prompt and efficacious will not interfere with 
the habits of a class led solely by its desires, then 

^^ Semper honor ^ nomenque tuum^ laudesque tnanebunty 

— Virgil. 

"Thy honor, thy renown, and thy praises shall be everlasting."' 

The intensity of the suffering in an attack of 
acute gout, usually podagra, is such as renders im- 
perative the demand of the patient for prompt relief^ 
and the physician does well to remember that he is 



-69- 

reckoned the wisest to whom that which is required 
at once suggests itself. 

The following may be ordered as a topical ap- 
plication: 

Q Ol. gaultheria 

Ol. olivae 

Linimentum saponis 

Tinct. aconiti 

Tinct. opii UH 3 »j- 

M. ft. linimentum et sig. Apply as directed. 

This can be applied freely by the gentlest fric- 
tion to the inflamed site, the foot and leg being then 
protected by a generous covering of cotton batting, 
or oakum, secured by a light bandage. The limb 
may then be supported upon an inclined plane, the 
foot being the higher point. If the pain be endur- 
able without the immediate call for analgesics, a 
carthetic should be given. The combination of 
cuonymin, leptandrin, podophyliin, and blue mass, in 
pill form as suggested in the treatment of chronic 
rheumatism will be found effectual. One or two of 
these pills may be administered. Alkaline treatment 
should be at once pushed. Bicarbonate of soda may 
be given in doses of one or two drachms to the 
tumblerful of water every four hours, for twelve or 
sixteen hours. It is difficult to lay down any hard 
and fast line in the matter of the treatment of the 
pain. If it be bearable at all, then the use of anti- 
pyrin will be of value in five grain doses every two 



— 70 — 

hours. This remedy, if found to be exerting its de- 
cided analgesic properties after the second dose, may 
be persisted in with the special advantage that it docs 
not preclude the early use and action of a cathartic. 
If, however, the pain is excruciating, as it often is, the 
treatment indicated is that which would be followed 
in any instance of acute suffering. Morphine with 
atropia, say morphia, gr. ^, atropia gr. yjg^, adminis- 
tered hypodermically near the inflammatory site, and 
repeated every half hour until the subsidence of pain 
to the point of endurance, will be all that is required. 
Acute attacks, referable to the gouty condition, 
which may manifest themselves in the internal organs, 
must be dealt with according to the exigencies of the 
cases and as indicated by the symptoms. If the 
heart becomes directly involved, that treatment and 
mode of life which determines the most perfect de- 
puration by the emunctories and insures to the organ 
itself blood of the best quality, will be most efficient 
means of preventing an early untoward issue. 
^ Here it may be well to enter a protest agamst 
the administration of colchicum in any of its forms, 
and the author, in the light of his experience, has no 
apology to make for discarding the use of this drug 
which custom, rather than individual discretion, has 
made the sheet anchor of treatment hitherto. Its 
effects are transient, it interferes with the digestion 
and circulation, induces muscular feebleness, and acts 
as an insidious general depressant. j Patients soon 



— 71 — 

learn to use it themselves, flying to it while persisting 
in the errors of living which render it necessary to 
their relief. The writer has no hesitation in stating 
a conclusion evolved from observation that many of 
the sudden deaths, among the wealthier classes, of 
men between fifty and sixty, ascribed to that vague 
causation, heart failure, are due to the improper use 
of colchicum. Indeed, it would perhaps often throw 
some clinical light, as guide to the physician in 
arriving at the causation in a case of heart failure, if 
he would inquire whether his patient, especially if 
known to have been a generous liver, has not been in 
the habit of administering to himself, or taking by 
medical or friendly advice, doses of colchicum or col- 
chicine. The use of any remedy which has for its 
aim the suppression of pain in gout, or indeed any 
disease, should never be so vaunted by the physician 
as to be popularized. Patients in this way get into 
the habit of dosing themselves without the slightest 
discrimination, and usually in such increasing quanti- 
ties that the toxic elements of the drug insidiously 
make their mark upon the constitution, tending, as in 
the case of colchicum, to a fatal termination. 

Education of the masses is a very beautiful phil- 
anthropic theory, and its practice an immense stride 
in the direction of an apochryphal millenium; but 
when it makes every man assume that he is living 
on the fruit of the Tree of Knowledge or has touched 
the hem of the garment of the Omniscient, it is apt 



— 72 — 

to prove a clog to the wheels of true progress. The 
auto-therapeutist of to-day is the bite noir of the con- 
scientious clinician. 

The diet during at acute gouty seizure must be 
limited to the most readily assimilated ingesta, chick- 
en and mutton broths, minus the fat, beef tea, vegeta- 
ble soups, and light puddings, being all that is re- 
quired. 

Following the subsidence of an acute attack of 
gout, bitter tonics should be given for two or three 
weeks. 

The condition of chronic gout will need careful 
and prolonged treatment, and, assuming the self- 
abnegation of the patient as posssble, and placing it 
as the sine qua non of success, it may be said to de- 
pend upon an observance of scientific dietetic rules, 
and alkalinization. Care should be taken to avoid 
abruptness in change of diet, but gradually there 
should be brought about such a form of dietary as 
will exclude the nitrogenous, saccharine, and acid ele- 
ments. With this principle ever to the fore, it is 
better to avoid any further dogmatic itemization, and 
thus lessen, as far as possible, the sense of restriction 
on the part of the patient. It is well, perhaps, to 
give a comprehensive list of the classes of food and 
drink which should be abstained from, and tell the 
patient he may take anything else in moderation out- 
side of this. While the stronger alcoholic drinks 
must be forbidden, the lighter white wines, taken with 



— 73 — 

carbonated water may perhaps be allowed with im- 
punity, and will often be appreciated by the patient 
as a very important condescension to his appetite. 

Alkalinization may be effected by the persistent 
use of any preparation which is found to be well 
borne by the stomach. For instance, equal parts of liq. 
potassae and infusion of buchu may be given in two- 
teaspoonful doses three times a day, after meals, in a 
tumbler of water, or Vichy water, or any of the alka- 
line preparations previously indicated for rheumatism 
may be used. The alkaline baths have been found of 
service, and when the means of the patient will justify 
the expedient, or a change of air is desired, those of 
Carlsbad and other celebrated resorts may be tried, 
though this is not essential in the treatment of gout, 
and will only be of use in conjunction with the ob- . 
servance of a prescribed regimen and constitutional 
treatment. A really valuable alkaline bath may be 
improvised ^at home by the addition of, say, half a 
pound of bicarbonate of soda to the ordinary bath 
at 90° F. 

It is a question whether massage is of marked 
utility, but it may be practiced where there is much 
joint stiffness, and will be more efficacious if per- 
formed upon the patient while in the- alkaline bath. 

The general drinks should be carbonated or 
lithia waters. Analyses of many of the various kinds 
are appended to this treatise, from which the physi- 
cian may choose snch as are, in his opinion, most 
indicated. The Londonderry water is, perhaps, 
especially useful from its richness in lithium. 




ANALYSES OF VARIOUS MINERAL WATERS. THE 

USE OF WHICH IS ESPECIALLY INDICATED 

IN THE TREATMENT OF RHEUMATISM 

AND GOUT. 

FOREIGN MINERAL WATERS— VICHY. 

^ - Grains Grammes Grammes 

GRA.NDE Grille. per Gallon. per Gallon. per Litre. 

Carbonate of Lime 12.28 0.8345 0.22050 

Carbonate of Magnesia. . 2.40 0.1555 0.04108 

Carbonate of Iron 0.64 0.0415 0.010Q5 

Carboate of Soda 276.88 17.9413 4.73940 

Sulphate of Soda 44*56 2.8873 0.76260 

Chloride of Soda 25.20 1.6329 0.43136 

Total 362. 56 23.4930 6. 20589 

HOPITAL. 

Carbonate of Lime 19.60 1.2702 0.33556 

Carbonate of Magnesia. . 2.16 0.1399 0.03697 

Carbonate of Iron 2.88 o. 1866 0.04930 

Carbonate of Sods 268.16 i7*3Bi3 4.59140 

Sulphate of Soda 50.16 3.2506 0.85867 

Chloride of Soda 8.80 0.5702 o 15066 

Total ..« 35176 22.7988 6.02256 




— 75 — 



THE BUBINAT LLOBAGH WATER. 





Grains 


Grammes 


Grammes 


1 


per Gallon. 


per Gallon, 


per Litre. 


Sulphate of Sodium 


5622.84 


364.3542 


96.265 


Sulphate of Potassium . . 


13.96 


0.9046 


0.239 


Sulphate of Magnesium. 


190.89 


12.3694 


3.268 


Sulphate of Calcium .... 


113.84 


7.3771 


1.949 


Chloride of Sodium .... 


120.04 


7.7784 


2.055 


Silica, Alumina and Fer- 








ric Oxide 


2.22 


0. 1438 


0.038 



Total 6063.79 392.9275 

THE YILLACABBAS WATER. 

Grains Grammes 

per Gallon. per Gallon. 

Sodium Sulphate 7129.22 461.977 

Magnesium Sulphate. .. . 57.52 3.727 

Calcium Sulphate 1 1 7. 1 2 7> 589 

Sodium Chloride 52.86 3.425 

Silica, Alumnia and Iron, 6.89 0.447 

Total 7363.61 477.165 



103.814 



Grammes 
per Litre. 

122.0500 
0.9847 
2.0005 
0.9050 

O.I 180 

126.0582 



-76- 



CABLSBAD MINEBAL WATEB. 

Grains 
perGanon. 

Carbonate of Iron 0.1752 

Carbonate of Maganese .... o.oi 1 7 

Carbonate of Magnesium, 9.2750 

Carbonate of Calcium 18.7700 

Carbonate of Strontium... 0.0235 

Carbonate of Lithium 0.7185 

Carbonate of Sodium 75.8200 

Sulphate of Potassium.... 10.8750 

Sulphate of Sodium 140.4810 

Chloride of Sodium 60.8550 

Fluoride of Sodium o. 2922 

Borate of Sodium o 2921 

Phosphate of Calcium 0.041 1 

Oxide of Aluminum 0.0235 

Silicic Acid 4.1760 

Carbonic Acid (partly comb.) 45.3300 

Carbonic Acid, free 11.0880 

Caesium, Rubidium, Thal- 
lium, Zinc, Arsenic, Anti- 
mony, Selenium, Formic 
Acid, Undeterminable 
Organic Matter Traces. Traces. Traces. 



Grammes 


Grammes 


per Gallon. 


per Litre. 


O.OI 14 


0.0030 


0.0007 


0.0002 


0.6302 


0.1665 


I.2165 


0.3214 


0.0015 


0.0004 


0.0465 


0.0123 


4.9141 


1.2980 


07049 


0.1862 


9.1040 


24053 


3.9440 


I.0418 


0.0189 


0.0051 


0.0189 


0.0050 


0.0026 


0.0007 


0.0015 


0.0004 


0.2706 


0.0715 


2.9374 


0.7761 


0.7184 


0.1898 



Total 378.6978 24.5421 6.4837 




— 77 — 



. AMERICAN MINERAL WATERS. 
PLUMMEB. BROMINE ARSENIC WATER. 

FROM ASHE COUNTY, N. C. 

Grains per Grammes per Grammes 

Galon. Gallon. per Litre. 

Sodium Carbonate i< 50553 0.09756 0.02577 

Calcium Carbonate .... 1. 18968 0.07709 o 02037 

Magnesium Carbonate o. 63508 o. 04 1 1 5 0.01087 

Lithium Carbonate 0.02152 0.00139 0.00037 

Copper and Lead Carbonate. . . Trace Trace Trace 

Zinc Carbonate Trace Trace Trace 

Calcium Fluoride Trace Trace Trace 

Potassium Sulphate 0.65199 0.04225 0.01116 

Potassium Chloride 0.13646 0.00884 0.00234 

Sodium Chloride o. 52136 0.03378 0,00893 

Sodium Arseniate 0.00758 000049 0.00013 

Sodium Bromide 0.03668 0.00237 aooo63 

Sodium Iodide 0.00944 0.00061 0.00016 

Ferrous Sulphate 0.09732 o 00631 0.00166 

Sodium Borate Trace Trace Trace 

Aluminium Phosphate 0.03720 0.00242 0.PO064 

Silica 1.88950 o. 12244 0.03234 

Organic Matter Trace Trace Trace 

Total 6.73934 0.43670 0.11537 



-78- 



LONDONDERRY MINERAL WATER. 

NASHUA, NEW HAMPSHIRE. 

Equal parts of East and West Springs mixed. 

Grains per Grammes per Grammes 

Gallon. Gallon. per Litre. 

Calciam Sulphate 12.5596 0.8138 0.2150 

Potassium Carbonate 9. 1642 o. 5938 o. 1569 

Calciam Bicarbonate 8,1249 o 5253 0.1387 

Magnesium Carbonate 7-6271 9 4943 0.1306 

Aluminic Sulphate 5.1726 0.3353 0.0885 

Iron Carbonate 1.8607 o. 1206 0.0319 

Potassic Sulphate o. 1541 o.oioi 0.0027 

Sodium Chloride 0.4290 0.0278 0.0077 

Silicia 0.6248 0.0409 0.0107 

LUJUum BicarbonaU 7. 1772 0.4651 o. 1229 

Total 52.8942 3.4269 0.9056 



INDEX. 



A. Page. 

Alkaline Mixture 24 

Amygdalitis 11 

Analgesics 27 

Antifebrin 27 

Antipyretics 27 

Antipyrin 27 

Argument i 

Summary of 5 

Arsenic 55 

B. 

Baths 32, 48, 73 

Bicarbonate of Soda 24, 69 

Bile in Acute Rheumatism 22 

Blisters in Acute Rheumatism. 32 

Bronchitis in Acute Rheumatism 49 

C. 

Cerebral Rheumatism 19 

Chemical Equilibrium, Disturbance of 2 

Cholagogue Pills 23 

Chorea 19 

Cinchona Bark 28 

Colchicum, Deleterious Effects of. 70 

Consumption and Rheumatism 10 

D. 

Diet in Acute Rheumatism » 29 

Chronic Rheumatism 41 

Rheumatoid Arthritis 55 

Gout % 72 



^ 



^ 8o — 

Page. 

Diet, the Salisbuiy ^ 41 

Digitalis 27 

Disease from Error in Chemical Action i 

E, 

E'ectricity 48, 59 

Euonymin 23 

Endocarditis 18 

F. 

Fibrin in Healthy Blood 2 

Flannel Clothing 48 

Follicular Tonsilitis 49 

G. 

Goat 60 

Causation of 60 

Course and Termination 66 

Definition of 60 

Physiology of 67 

Symptomology of ^3 

Treatment 68 

H. 

Heart Complication in Acute Rheiunatism 18 

Heart Tonic 29 

Hydrops Articuli 52 

Hyperpyrexia in Acute Rheumatism 33 

I. 

Iodine Ointment 47 

L. 

Lemon Juice in Drinks 30 

Liniments 46, 47 

Litbia Waters, Londonderry 45, 73 



— Si — 

Page 

Lithium, Bromide, of i 44 

Salicylate of, 44 

Lotions 31 

M. 

Massage 33, 46. 59» 73 

Meat, Abstinence from 40 

Morphine 27, 44, 59, 70 

Myocarditis in Acute Rheumatism 17 

O. 

Ointment, Iodine 47 

P. 

Pericarditis in Acute Rheumatism 17 

Pharyngitis in Acute Rheumatism 49 

Phenacetin 27 

Plummer Bromine Arsenic Water 59 

Podophyllin 23 

R. 

Rheumatism, Acute Articular 7 

Alkalies in 23 

Amygdalitis in 11 

Analgesics in 27 

Antipyretics in 26 

Baths in 32 

Causation of 7 

Cholagogues in 22 

Climatic Influences in 8 

Complications in 17 

Course and Termination 16 

Definition of 7 

Dietetics in 29 

Differential Diagnosis 14 

Exciting Causes of 9 




— 82 — 

Page. 

Rheumatism, Acute Routine Treatment in 21 

Laryngitis ii 

Massage 33 

Microblc Origin of 7 

Mineral Waters in 28 

Non-existence of with Phthisis 10 

Pathology of 15 

Predisposing Causes of 8 

Skin Eruptions in 13 

Specific Remedies in 20 

Symptomatology of 11 

Temperature and Pulse in 13, 14 

Tonics 28 

Topical Applications 31 

Treatment of 20 

Uric Acid Theory of 7 

Urine in 13 

Rheumatism, Chronic Articular 35 

Alkalies in, 43 

Analgesics .44 

Baths 48 

Causation of 35 

Cholagogues in 42 

Clothing 48 

Course and Termination of 38 

Definition of 35 

Diagnosis 39 

Electricity in 48 

Local Treatment of 46 

Massage in 47 

Mineral Waters 45 

Pathology 38 

Symptomatology of 37 

Tonics in 45 




- 83- 

Page. 

Rheumatism, Chronic Treatment of 40 

Rheumatoid Arthritis 50 

Causation 50 

Definition 50 

Pathology 52 

Symptomatology • 51 

Treatment 54 

S. 

Salicylates, Deleterious Effects of 25 

Salicylism 26 

Salisbury Diet. . . 41 

Salol .'.... 44 

Skin Eruptions 13 

Sodium Bi-carbonate 24 

Phosphate 24 

Sulphonal : 44 

Sulphur Baths .... 32 

Super-oxidation of Tissue in Pyrexia 4 

T. 

Tonic Mixtures 29 

Topical Applications in Acute Rheumatism 31 

U. 

Uric Acid and Urea 1-6 

V. 

Vichy Water 28 

Villacabras Water r 46 

W. 

Waters, Analyses of Mineral 74 




EMIile Reiedies for iemitisi. 



Elixir Manaca and the Salicylates. 

In its native country, Brazil, Manaca is regarded as a specific for 
the cure of rheumatic affections, and the results obtained by its extensive 
trial in this country have confirmed the opinions of the Brazilian pro- 
fession. 

The value of the Salicylates in rheumatism is too well known to 
need more than mention. 

This elixir combines the virtues pf Manaca with those of the Sali- 
cylates of Sodium, Potassium, and Lithium, and will be found a most 
reliable and convenient form for securing the anti-rheumatic effects of 
these agents. 

Working Bulletin on Manaca mailed to Physicians on request. Sam- 
ples supplied for investigation. 



CASCARA SAGRADA IN RHEUMATISM 



Reports of Cascara Sagrada, so long well known for its value in the 
treatment ot chronic constipation, have shown its curative action in 
rheumatism. (See article entitled "Cascara Sagrada in Rheumatism," 
by T. H. Goodwin, M. D., surgeon U. S. Marine Hospital Service, New 
York Medical Journal^ June 9, 1888). In thirty cases the most satisfac- 
tory results were obtained, and relief was afforded in most cases in 
twenty- four hours. 

The facts already observed encourage its further employment, both 
alone and in combination with the Salicylates. The palatable prepara- 
tions of Cascara Sagrada, as Cascara Cordial, make an excellent vehicle 
for the Salicylates, tending to prevent the distressing cerebral symptoms 
of the latter. (See article by R. S. Henry, M. D., Philadelphia Medical 
and Surgical Reporter^ Oct. 23d, 1886), and a combination of these drugs 
will secure the remedial action of both. 

A reprint of Dr. Goodwin's article on ** Cascara Sagrada in Rheu- 
matism,'^ mailed physicians on request. 

PARKE, DAVIS & CO., 

DETROIT AND NB^W YORK. 



IN EXPLANATION 



OF 




FbysiciiiDs' Leisure Librair. 



We have made a new departure in the publication of medical books. As you 
no doubt know, many of the large treatlBes published, which sell for four or five or 
more dollars, contain much irrelevant matter of no practical value to the physi- 
cian, and their high price makes it often impossible for the average practitioner to 
purchase anything like a complete library. 

Believiog that short practical treatises, prepared by weU known authors, c<hi- 
tainlng the gist of what they had to say regarding the treatment of diseases com- 
monly met with, and of which they had made a special study, sold at a small price, 
would be welcomed by the majority of the profession, we have arranged for the 
publication of such a series, calling it Tlie Pliyslclans' Ijelsure I«lbrary« 

This series has met with the approval and appreciation of the medical profes- 
sion, and we shall continue to issue in it books by eminent authors of this country 
and Europe, covering the best modem treatment of prevalent diseases. 

The series will certainly afford practitioners and students an opportunity 
never before presented for obtaining a working library of books by the best authors 
at a price which places them within the reach of all. The books are amply illus 
trated, and issued in attractive form. 

They may be had bound, either in durable paper covers at 25 €ts« per copy, 
or in cloth at 50 €ts, per copy. Complete series of 12 books in sets as announced, 
at $2*509 in paper, or cloth at $5,009 postage prepaid. See complete list. 



PHYSICIANS' LEISURE LIBRARY 



PRICEi PAPER, 25 CT?, PER COPY, $2.50 PER SET; CLOTH, 50 CTS. PER COPY, 

S5.00 PER SET. 



SERIES I. 



^nh 



nts. 




lalerSi Inhalations find Inhalan 
By Beverley Robmson, M. D 

The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes., _ 
By iJeo. Henry Fox, M. D. 

\New Medications, in 2 Vols. 

By Dujardin-Beaumetz, M. D. 

The Modern Treatment of Ear Diseases. 
By Samuel Sexton, M. D. 

By'*Henry J. Gsurrigues, M. D. 



On the Determination of the Necessity for 
Wearing Glasses. , ^ 

By D. B. St. John Roosa, M. D. 

The Physiological, Pathological and Ther 
apeutic Effects of Compressed Air. 
By Andrew H. Smith, M. D. 

GranularLids and ContagiousOPhthalmla. 
By W. F. Mittendorf . M. D. 

Practical Bacteriology. 

By Thomas B. Satterthwaite, M D 

Pregnancyi Parturition, the Puerpera 
State and their Com plications. 
ly Paul F. Mund%, M. D. 



The Pjagnotisand Treatment of Haemor- 

By Chas. B. Kelsey, M. D. 

-Ditaatat of the Heart, in 2 Voitt 
By Dujardin-Beaumetz, M. D. 
Translated by B. P. Hurd, M. D. 

The Modem Treatment of Diarrhoea and 
Dysentery. 

By A. B. Palmer, M. D. 

intestinal Diseases of Children, in 2 VolSt 
By A. Jacob!, M. D. 



SERIES II. 

The Modem Treatment of Headaohes. ^ 
By Allan McLane HamUtoii, M. D. 



The Modern Treatment of Pleurisy and 

By 6. M.' Garland, M. D. 

Diseases of the Male Urethnu ^ 
By Pessenden N. Otis, M. D. 

The Disorders of Menstruation. , 
By Edward W. Jenks, M. D. 

The Infectious Diseaseii. ^ ■ ▼ol>» 

By Karl Liebermeister. 

Translated by B. P. Hurd, M. D. 



SERIES III. 



Abdominal Surgery 

By Hal C. Wyman, M. D. 

Diseases of the Liver. 

By Dujardin-Beaumetz, M.D. 

Hysteria and Epilepsy. 

By J. Leonard Coming, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice of the Ophthal- 
moscope. 

By J. Herbert Claiborne, Jr., M. D. 

Modern Treatment of Bright's Disease. 
By Alfred L. Loomis, M. D. 



Clinical Lectures on Certain Diseases of 
Nervous System. 

By Prof. J. M. Charcot, M. D. 

The Radical Cure of Hernia. 

By Henry O. Marcy, A. M., M. D., 
L. L. D. 

Spinal Irritation. „ . .. -^ 

By William A Hammond, M. D. 

Dyspepsia. 

By Frank Woodbury, M. D. 

The Treatment of the Morphia Habiti 
By Brlenmeyer. 

The Etiologly, Diagnosis and Therapy of 

By Prof. H. von Ziemssen. 
Translated by D. J. Doherty, M. D. 



SERIES nr. 



Nervous Syphilis. 

By H. C. Wood, M. D. 



rrelated to 



Education and Cvlture as cq 

the Health and Diseases ofwomen. 
By A. J. C. Skene, M. D. 

Diabetesi 

By A. H. Smith, M. D. 

A Treatise on Fractures. 

By Armand Despres, M. D. 

Some Major and Minor Fallacies con- 
coming Syphilis. 

By B. L. Keyes, M. D. 

Hypodermic Medication. 

By Boumeville and Bricon. 



Diseases of Children _ 
By I.N. Love, M. D. 



Practical Points in the Management of 
""' of Chi'" 

r. L. 

Neuralgia. 

By E. P. Hurd, M. D. 

Rheumatism and Gout. . ^ 

By F. Le Roy Satterlee, M. D. 

Electricity, its application in Medicine. 
By Wellington Adams, M. D. 

By F. H.' Bosworth, M. D. 

A usQultetion and Percussion. .. ^ 
By Frederick C. Shattuck, M. D. 



Series IV will hm issued one a month, beginning with November, ISSP* 



GEORGE S. DAVIS, Publisher, 

'. O- Boac 4f70. 



LANE MEDICAL LIBRARY 

To avoid fine, thia book should be retunied 
311 or before the date last Btaniped below. 




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